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C h a p t e r 1 1

FUNCTIONAL FAMILY THERAPY: AN EVIDENCE-BASED,

FAMILY-FOCUSED, AND SYSTEMIC APPROACH FOR WORKING WITH

ADOLESCENTS AND THEIR FAMILIES Thomas L. Sexton

Successfully helping families change remains one of the most complex therapeutic tasks faced by clinicians (Sexton et al., 2011). In part, this is because families are complex relational systems in which visible behaviors are represented by multiple layers of meaning and perspectives that come together to form stable, enduring family relational patterns. Families that come into treatment go through the same complex relational processes that all families experience, but with the additional challenge that the behaviors in the relational patterns among people in the family are not functional, may be harmful, or don’t fit well within the context in which they live. In these families, the clinical symptoms we see and hear about in therapeutic interviews have become not only things people do but also the core patterns of behavior among people that somehow get stuck in trying to solve the challenges of everyday life. In these cases, the very same systemic forces that bind these families make it difficult for them to move forward and change (Sexton & Stanton, 2016).

Functional family therapy (FFT) has a long history as a treatment model for youth and adolescent conduct problems, drug use, and other mental health concerns (Alexander & Parsons, 1973; Gurman & Kniskern, 1981; Sexton, 2010, 2016). As a theoretical model, FFT is among the early generations of family

therapy models that were built on the core principles of systemic thinking, as well as the early family therapy theoretical models, including structural family therapy, early social constructivist approaches, and the interactional ideas of the early Mental Research Institute approach. In more recent years, FFT has been recognized as one of the premier evidence-based family intervention models (Kazdin, 2013) for working with adolescents with problem behaviors. FFT is unique in the field of couple and family psychology in that rather than comprising a toolbox of collected therapist techniques, it is a comprehensive family-based and relationally focused clinical intervention model that that is more of an architectural plan than a series of isolated clinical techniques (Sexton, 2010).

In practice, FFT is a dynamic, highly interpersonal, relationally focused therapeutic experience that relies on the collaborative and relational nature of the interactions among client, family, and therapist as the mechanism of change. It is the FFT therapist who successfully translates the model from ideas to the interactions between the therapist and the family. In these interactions, therapists follow a model (i.e., a map), and are guided by core principles (i.e., a lens), yet are dependent on their own creativity in matching to the unique structure, functioning, and interaction style of the family. The creativity of the therapist in

http://dx.doi.org/10.1037/0000101-011 APA Handbook of Contemporary Family Psychology: Vol. 3. Family Therapy and Training, B. H. Fiese (Editor-in-Chief) Copyright © 2019 by the American Psychological Association. All rights reserved.

APA Handbook of Contemporary Family Psychology: Family Therapy and Training, edited by B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, and M. A. Whisman Copyright © 2019 American Psychological Association. All rights reserved.

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implementing the model within the structure of FFT results in good outcomes for some of the most difficult clinical cases. Over time, FFT has evolved from a theory to a treatment model that blends both structure and creativity into a systematic approach to working with some of the most difficult types of clinical cases. Over its 30 years of evolution and development, FFT has matured to include a comprehensive theoretical lens, a systemic relationally based change process (or map), and an appreciation and reliance on the clinical creativity of the therapist who translates the model from an idea into practice in the relational interactions with the client and family.

FFT has been extensively written about in many of the core references in the field (Barton & Alexander, 1981; Sexton, 2016; Sexton & Alexander, 2003). This chapter builds on these earlier works while including the newest developments in the evolution of the model. The chapter is organized in six sections: (a) the evolutional path in the development of the FFT clinical model, (b) the theoretical lens, (c) the clinical map and the critical role of the therapist, (d) the specific methods of evaluation, (e) the research foundations of the model, and (f) measurement evidence-based decision making that facilitates good outcomes.

THE HISTORY OF FUNCTIONAL FAMILY THERAPY: EVOLVING, ASSIMILATING, AND ADAPTING

FFT is unique as a theoretical model because of its dynamic and evolving nature. Rather than remaining static, the principles and techniques of FFT have evolved and continue to evolve (Sexton & Alexander, 2003). Initially, FFT developed due to a clinical need in communities, schools, and community-based treatment centers that serve a population of at-risk adolescents and families who were often perceived to be difficult to treat and difficult to engage. Early descriptions of FFT relied on relatively simplistic behavioral technologies such as communication training (Alexander & Parsons, 1973) and common systemic principles. This led to the classification of FFT as a behavioral approach (Gurman & Kniskern, 1981). As the model evolved, aspects of cognitive theory—particularly the concept

of attribution as well as information-processing theories—helped explain some of the mechanisms of meaning and emotion that often manifest as blaming and negativity. Social constructionist ideas about the role of meaning in the constructed nature of problems, in interrupting family negativity, and in organizing therapeutic themes and risk and protective factor models also added to FFT (Sexton, 2010, 2016; Sexton & Alexander, 2003). Much like its early systemic roots, current FFT is built on notions, patterns, contexts, and perspectives aimed at understanding the ways in which the relational systems of families get stuck.

As the FFT model has matured, attention has turned to ways to make FFT effective as it is practiced in community-based settings. Currently, FFT is practiced in eight different countries in six different languages, within diverse cultural contexts and service delivery systems. Sexton and Turner (2010); Graham, Carr, Rooney, Sexton, and Satterfield (2013); and Hartnett, Carr, and Sexton (2016) found that positive outcomes of FFT in community-based settings were the result of an interaction between the model and the fidelity of the model as implemented by an individual therapist. Thus began an effort to understand what it takes to implement an evidence-based model like FFT in a community setting. These efforts have resulted in a manual-driven approach to clinical supervision (Sexton, Alexander, & Gilman, 2004), a computer- based quality improvement system that serves as a measurement feedback tool (FFT-Care4) to guide clinicians in following the model and matching to clients (Sexton, 2010, 2016; Sexton & Fisher, 2016), and a systematic approach to training and implementation (Sexton, 2016). Over time, FFT has become what Sexton and Alexander (2006) called a comprehensive service delivery model, including a comprehensive theory, a specific clinical protocol, a reliable and valid measurement system, and decision-making tools to help improve outcomes. Today, the notions of continuous process assessment and systematic evidence-based treatment planning bring clients’ voices into clinical decision making through feedback, which is a central principle in FFT practice. This approach also allows for ongoing research and model development.

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THEORETICAL CORE: THE LENS OF FUNCTIONAL FAMILY THERAPY

A lens is a useful metaphor for understanding the core theoretical principles of FFT. Lenses help bring objects into focus in a way that pulls out certain details so as to define particular characteristics. Looking through a lens helps highlight extensive information in an understandable way. FFT focuses on the “space between” family members and the interactions among them in order to understand behavior and therapeutically intervene. In this way, FFT is a process-based, rather than content-based, approach. Five core theoretical principles, as follow, shape how FFT helps clinicians to understand the families and individuals they work with and the clinical change process that they will follow in helping them change.

Principle #1: Families Are Stable Multisystemic Relational Systems FFT is based on the principle that all behavior is part of a multisystemic relational system with multiple, mutually interactive components including youth, parents, family system, extended family, and community, among others. From this perspective, problem behavior is viewed as a complex interaction between the specific behavior that is embedded with a relational pattern and the influence of many systems in the context around the family. The concepts of risk and protective factors provide a comprehensive, clinically specific way to identify the potential strengths and weaknesses of youth and families within the multilayered, multisystemic system. Risk factors are those elements within the broader system that increase the likelihood of problem behavior whereas protective factors are elements of the family system to retrain and build upon. The presence of single risk factors does not cause antisocial behavior; instead, multiple risk factors combine to contribute to and shape behavior over the course of individual development. It is the confluence of risk and protective factors that determines the likelihood of risk-taking behavior rather than any single characteristic of family structure or youth or caregiver behavior. When one takes a multisystemic perspective, it becomes clear that the source of a family’s difficulties is not one individual’s

problem behavior but the way it is managed within the family system and the surrounding context.

Principle #2: Relational Patterns Are Central to Family Relationships Family relational patterns are unspoken connections that organize, structure, promote, support, and thus also encourage and maintain the behaviors and emotions seen when observing a family. The patterns are a bit like a spider’s web, in which any single element in the web is connected by innumerable, smaller, subtle strands to other elements. While hard to see, multiple strands of connection link each member to the others in the immediate and extended family. These strands define the family relationships, and like those of the spider’s web, hold the relationships together. The implication is that moving any one part moves all the others. Pulling one part out results in a resistance or pull back from other parts, and to understand any part, the whole relationship must be considered (Sexton & Stanton, 2016). In FFT, we define family relational patterns as those common behavioral sequences among family members that, over time, become a common way of interacting. Core relational patterns become the typical way in which relational systems respond to events that occur around them.

Relational patterns can be a source from which to identify critical risk/protective patterns as maintained and supported by the ways in which relationships function. There are a number of normal (e.g., family life cycle changes) and abnormal (e.g., trauma, abuse) events in life that require individuals, couples, and families to cope through adaptation and adjustment. Over time, the very solutions used to address the situation become part of the family’s central relational patterns. Beliefs and narratives develop that characterize the problematic behavior in ways that, despite all the family members’ attempts to help, become part of the system that maintains the problem. Thus, clinical problems are events which the individual or family was unsuccessful in adapting to, resulting in an ongoing pattern of problem- maintaining behaviors and beliefs that reinforce the problem and serve to make the family stuck, unable to adapt and successfully solve the clinical problem at hand.

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Principle #3: Problem Narratives and Attributions Form the Meaning Dimension of Understanding Families Problem narratives and attributions that develop around relational patterns also contribute to the development and maintenance of clinical problems (Sexton & Stanton, 2016). Attributions play a role in defining the intentions of the person exhibiting the problem behavior. When family members attribute negative characteristics or intentions to each other, these attributions may lead them to persist in problem-maintaining behavior and elicit problem-maintaining behavior in others (Carr, 2013). Belief systems also support and maintain problem behaviors through attribution of intent to other behaviors and beliefs about the relationship. In each case, the beliefs, narratives, and attributions about others and the source of problem behaviors play important roles in understanding clinical problems systemically (Sexton & Stanton, 2016). In FFT, we describe these attributions with the term individual and family problem definitions. Problem definitions are cognitive sets that help create meaning around the problem, describing who is responsible for the problem, why it is important, and why it occurs. Problem definitions are the description given to the therapist by family members when asked, “What is the problem?” The resulting descriptions from each family member represent each person’s natural and normal attempts to understand what is causing the pain and struggle in the family.

Principle #4: Youth Behavior and Clinical Problems Are Family Problems From an FFT perspective, there is not a “cause” for the difficulties experienced by the family members. Instead, individual problems are seen as embedded within core family relational patterns, which represent the way the family interacts around the problem behavior. In accordance with the concepts of the systemic relational process, these patterns become very stable and, once established, they perpetuate problem behaviors. Thus, both youth and their caregivers are part of the development and maintenance of both positive and helpful behaviors as well as clinically symptomatic behaviors. This

is why all FFT treatment interventions are family focused and involve all family members.

Principle #5: Families Are “Glued” Together Through Relational Attachments or Functions That Help Explain the Homeostatic Nature of Family Relational Systems The quality and characteristics of how people are attached are important elements in understanding how families function. In many ways, these features may explain why a family is stable, how it maintains it uniqueness, and how they can get stuck. From an FFT perspective, relational attachments are described as relational functions that represent a way to understand why, despite the painful processes they produce, problems endure in family relational systems. Relational functions are the attachments that hold seemingly dysfunctional and painful patterns of behavior together over time. In a sense, relational functions are the outcomes of the relational patterns central to the family. Over time, it is the functional outcomes rather than the unique steps in relational patterns that unify relationships. Regardless of their form, the common, repetitive, and highly entrenched behavioral sequences apparent in families lead to consistent relational outcomes that can be understood only from an ideographic perspective. In other words, so-called maladaptive behavioral patterns represent people meeting their relational functions in ways that make sense given their unique learning histories, capacities, and environments, yet have a negative impact and stand in the way of successful current functioning (Sexton & Alexander, 2003).

In FFT, there are two main dimensions of relational functions within the family: relational connection and relationship hierarchy (Alexander & Parsons, 1982; Sexton & Alexander, 2003). Relational connection (or interdependency) refers to the characteristic pattern that describes a relationship in terms of the degree to which high rates of mutual and emotionally vulnerable contact are necessary to maintain the relationship (Sexton & Alexander, 2004). High degrees of relatedness (relational interdependency) are experienced not only as a sense of interconnectedness but also in terms of psychological intensity in regards

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to frequency of contact in the relationship, emotional contact, and/or enmeshment. Feelings of autonomy, distance, independence, low degree of psychological intensity, and prolonged contact characterize low degrees of relatedness. The high and low degrees of relatedness are not different ends of a continuum, but instead represent two dimensions, both of which are evident to some degree in the experience of a relationship (Sexton & Alexander, 2004). Midpointing is an experience of a relationship represented by both high connectedness (interconnectedness) and distance (independence).

Relational hierarchy is a different dimension of relational functions. This dimension is a measure of relational control and influence based on structure and resources (Sexton & Alexander, 2004). Hierarchical influence ranges from high to low, with relational symmetry being an experience of balanced structure and shared resources in the relationship. So-called “one-up” and “one-down” relationships are ones in which one member of a relationship has influence through resources (e.g., economic power, physical power, positional or role power supported by external systems) that are less available to the other member(s) in the relationship.

FFT is unique in its use of relational functions. Other therapeutic approaches seem to value certain functions (e.g., valuing closeness and pathologizing relational distance). From the FFT perspective, there is nothing wrong (or to be changed) with respect to any of these experiences (e.g., having a sense of control, receiving attention, having a sense of belonging). As a result, FFT therapists don’t attempt to change the core relational functions of the family members. In fact, FFT argues that different cultures, family configurations, and learning histories produce and value a wide range of relational patterns, and that each of these patterns can produce both positive and negative behavioral expressions. Relational functions are guides for the therapist in determining how to match common treatment interventions with each member of the family. Thus, rather than target the closeness or distance between an adolescent and parent, the task is to change the behaviors in the pattern while retaining the degree of connection of influence currently existing in the relationship. For example, with a youth and parent that are highly

interdependent relationally, the therapist may shape the interaction to be more emotional, more intense, more frequent, and more in depth. With a different family, the same clinical intervention may be done with lower emotional intensity, less frequently, and more briefly. Thus, FFT changes the pathway to the functional outcome while letting the functional outcome be determined by the family. Using a different metaphor, FFT clinicians do not attempt to change the personality of the family (relational functions) but rather their way of managing that personality (behaviors).

CLINICAL INTERVENTION MODEL

There are five core principles of the FFT clinical model. These principles form the basis and foundation of the phases of FFT treatment as well as the temporally specific phase goals and the individual therapist intervention techniques designed to help accomplish those goals.

1. Successful change is alliance based and family focused. Developing within-family alliance is a central intervention that helps build client engagement and motivation to change. The facilitation of trust and agreement on the goals and tasks of therapy is complicated in that family members often present with differing goals, levels of investment in therapy, and conflicting ideas about what will lead to change. The development of within-family alliance helps create the feeling that all family members are part of the problem and the solution to overcome the problem in the family. Within-family alliance is promoted by assisting family members in addressing these differences through the formation of family relational themes that describe the common struggles and common goals that need to be addressed in order for each member to feel that he or she is part of the process. The universal consensus required to set common treatment goals is a method used to build and maintain within-family alliance bolstering trust, reducing negativity, and reducing blame between the family members and the counselor, and among the family members themselves, thus facilitating

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a shared sense of purpose among family members (Friedlander, Escudero, Heatherington, & Diamond, 2011).

2. Therapeutic change is temporal and occurs in phases. When more than one client is in the room, the patterns and struggles among family members become very apparent. Historically, family-based treatments were viewed as discrete interactions that happened in treatment, whereas therapy was seen as a response to what the client needed at the time. More current treatment models, such as FFT, suggest utilizing a somewhat different approach. Although treatment does need to respond to the needs of the family members, it is also temporal and developmental. What this means is that the early stages of FFT are specifically and purposefully directed at helping each family member engage in treatment and gather motivation. The middle stages of treatment are focused on developing new skills that can be built on the early engagement and motivation of the family. Finally, ending treatment builds on both the engagement of the first phase, the new skills developed during the second, and the final goals of maintaining and generalizing change. In this way, FFT treatment progresses from the beginning to the end of a process of change that is developmental, with each phase building on the one that came before.

3. Treatment goals are obtainable ones that fit the family. For any family engagement, motivation and positive outcomes are dependent on finding ways to make treatment meaningful, relevant, practical, and lasting. Thus, a core principle of FFT is that any change goals need to be significant, yet obtainable, behavioral changes that will have a lasting impact on the family. Therapists using the FFT model seek to pursue obtainable outcomes that fit the values, capability, and style of the particular family in treatment, rather than to mold families into a prototypical and culturally bound version of what it means to be healthy. Specific and obtainable behavior changes have a major impact on family function because they are targeted in order to alter the underlying risk and protective patterns that support and maintain other problematic

behaviors. Thus, what might appear to be small behavior changes in family processes (e.g., positive parental monitoring; reduction between family members in blame) are ones that are lasting, because they enhance the relevant protective factors and decrease the important risk factors in the individual family in treatment. By pursuing obtainable changes that occur in these families, FFT not only has the immediate effect of changing the experience of a specific problem but also has an additional impact on actually changing the way in which families function, thus empowering families to continue applying changes to future circumstances. Thus, what may seem like a small change may become, over time, a significant and lasting alteration in the functioning of the family that is reflected in major changes in behavioral outcomes, such as cessation of drug use and within-family violence.

4. Therapy involves two experts: Therapists are active experts in the change process, collaboratively working with clients who are experts on their lives. FFT considers both the therapist and the clients to be central in treatment. Sexton (2016) suggested that the therapist functions “as both an independent factor and a key link within the therapy process” (p. 106). As such, the role of the therapist is one of a purposeful facilitator of the core mechanisms and process of change, adapting and adjusting the treatment model to the unique idiosyncratic nature of the client or family (Sexton, 2010). The role of the FFT therapist is as a “translator” of the FFT clinical model to the client relational system (Sexton, 2016). In FFT, the therapist brings and translates a model to the clients through their relational interactions. Family members are experts in the culture, values, style, and other unique characteristics of that unique family. As such, family members are also critical experts in the FFT treatment process. The family’s focus is on not the process of change but on its proximal and distal outcomes—feeling better, getting along, and functioning in a healthy way.

5. Evidence-based clinical decision making results in better outcomes. In real-life clinical settings, clinicians must make decisions about adapting treatment to the needs of clients they serve.

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To do so, clinicians must be able to evaluate whether a client is improving, remaining stable, or deteriorating. To do so successfully, clinicians require sources of information other than clinical observation to understand the therapeutic process and progress of their clients. FFT is unique in that it also developed a model-specific measurement and clinical feedback system (Sexton, 2010, 2016) that allows for reliable session-by-session measurement of symptoms, model impact, and progress; these features are part of a web-based feedback tool that provides specific evidence with which to make clinical decisions and session plans. The combination of case planning tools, proximal measures of session impact and progress, and longer term measures of outcome allows for a means to practice FFT in an evidence-based way. In the following section of this chapter, the manner in which FFT integrates evidence into a process- based decision-making model is discussed.

PHASES OF FUNCTIONAL FAMILY THERAPY

A map is a useful metaphor to describe the clinical protocol of FFT. The FFT clinical protocol is made up of three systematic and temporally organized phases of clinical mechanisms, specific goals, and relational outcomes: engagement/motivation, behavior change, and generalization. Each phase has particular goals and intervention strategies that are specifically designed to address those goals. FFT phase goals are proximal process goals (i.e., intermediate steps to lasting family change). When used by therapists, the protocol becomes something like a map of change, leading from the most important initial steps to the final steps of helping maintain changes. When the protocol is followed by the family, it takes the form of a seamless process and conversation that is highly personal, specific, and relevant to the issues of most concern, while engaging all family members. This change model provides a map to guide the therapist through the intense, emotional, and conflicted interactions presented by the family (Sexton & Alexander, 2004; Sexton, 2010). Each of the three phases of FFT

sets distinct goals and utilizes therapist skills that, when used competently, maximize the likelihood of successful accomplishment of those goals. Each phase also has specific foci, interventions, and desired proximal outcomes that form the building blocks of change. Figure 11.1 illustrates the three phases of FFT.

Phase 1: Engagement and Motivation Phase The initial phase of FFT treatment has three primary objectives that are designed to facilitate engagement and motivation and create the foundation for later treatment phases: building balanced alliances (among family members and between each family member and the therapist), reducing between-family blame and negativity, and developing a shared family- focused problem definition that matches the family’s relational functioning. The desired outcome of these early interactions is that the family develops motivation by experiencing a sense of support in their position, emotions, and concerns; a sense of hope for change; and a belief that the therapist and therapy can help promote those changes. When negativity and blaming are reduced, more positive interactions among family members foster hope. This outcome allows the therapist to demonstrate that she or he is a competent force that is capable of guiding the family toward change. An alliance develops wherein each family member believes that the therapist supports and understands his or her position, beliefs, and values.

When families begin therapy, they arrive with a history of having struggled with the behavior problems of an adolescent and/or parent for some time. It is only natural, and maybe quite uniquely human, that we all try to make sense of what has happened and is happening. As a result, each family member comes to therapy with beliefs about who caused the problems, assumptions about the others’ intentions, and a broader idea about the cause of the problems in the family (problem definitions). These problem definitions contribute to the emotional intensity that is often behind the anger, blaming, and negativity seen in interpersonal interactions between family members. One of the major challenges in early stages of FFT is that there are as many definitions and meanings of what the problem is as there are family members. In fact, much of the negativity

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Goals

Goals Alliance between family

with therapist

Family/relationally

based problem/problem focus

Reduced family member

negativity/blame

Increased motivation

Generalize new view and experience of problem with

new problems that arise

Maintain new skill—working together

with new problems

Support changes by using relevant outside resources

Behavior Change

Assessment

Intervention

Goals Increase behavioral competency of all/family

Consistent performance of competency

in real problem situation

GeneralizationEngagement & Motivation

FIGURE 11.1. Functional family therapy clinical model. From “Functional Family Therapy: Evidence-Based and Clinically Creative,” by T. L. Sexton, in Handbook of Family Therapy (p. 261), by T. L. Sexton and J. Lebow (Eds.), 2016, New York, NY: Routledge. Copyright 2016 by Taylor & Francis. Adapted with permission.Co

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and blame that fuels troubled interactions among family members comes from each member feeling the conflicting clash of different experiences of the source of the problems and thereby the solutions that seem to have the most potential to produce the changes that will eliminate anger and pain.

Reframing, a central technique in FFT, was initially made popular by early communication theorists and strategic therapists (Selvini-Palazzoli, Boscozo, Cecchin, & Prata, 1978; see Chapter 8, this volume) and has become one of the most universal therapeutic techniques used across all family therapies. In FFT, reframing is a relational intervention that is designed to create alternative cognitive and attributional perspectives that help redefine meaningful events in order to reduce negativity and redirect the emotionality surrounding those events. Reframing helps to identify new directions for future change and link family members to one another, so that each individual shares in the responsibility for family struggles. Unique to FFT is the view that reframing is an ongoing relational process of collaborative meaning making between the therapist and family members, rather than a static event in which something is relabeled. This view of reframing is rooted in the attributional and information processing constructs of cognitive psychology, social influence processes of social psychology, and the more recent systemic (Claiborn & Lichtenberg, 1989) and social constructionist ideas regarding the meaning basis of problem definitions (Friedlander & Heatherington, 1998; Gergen, 1985; Sexton & Griffin, 1997). Reframing is used to reattribute and refocus meaning, change emotional reactions to events, and help identify the noble intentions of each family member. Over time, reframing results in a larger meaning change called a family relational theme.

The first step of relational reframing is one in which the therapist acknowledges and clearly identifies the issues raised by the client. The acknowledgment demonstrates support, understanding, and respect for the client. To be successful, the acknowledgment avoids broad generalizations (e.g., “all parents feel this way”) and instead focuses on personal, individual, and insightful statements, so that the client believes the therapist to be working

hard to understand his or her unique perspective. Acknowledgment is followed by a reattribution statement, which presents an alternative theme that targets the attributional scheme embedded in the client presentation. The reattribution statement can take many forms, including offering an alternative explanation for the cause of the problem behavior that fits the client. The alternative meaning or theme that changes the perceived intentions of other family members to more benign attributions must be plausible and believable to the client. As described by Sexton and Alexander (2003), it is possible to reframe anger as the hurt that an individual feels in response to trouble in the family. Reattribution is helpful because it changes the focus on the behavior from being directed toward another person to the speaker. Thus, the blame inherent in anger is now redefined as hurt and even sacrifice, which helps the client remove negative emotions while retaining behavioral responsibility. The cognitive sets, or problem definitions, are the meanings that contribute to the emotional intensity that is often behind the anger, blaming, and negativity seen in interpersonal interactions among family members. Figure 11.2 illustrates the steps of relational reframing in FFT.

Reframing does not end with a therapist interven- tion. As noted above, in FFT, relational reframing is an ongoing process. The acknowledgment and reframing statements of the therapist are followed by an assessment of the “fit” (i.e., an assessment of how well the intervention matches the style of the family), by listening to the client’s response, and incorporating changes or alternative ideas into the next validation and reframing statement from the therapist. In this way, reframing is a constant feedback loop between therapist and client interactions that builds toward the therapeutic goal. As a process, the therapist and the client are actually constructing a mutually agreed upon and jointly acceptable alternative explanation for an emotional set of events or series of behaviors. Because it is jointly constructed, it is real and relevant to both client and therapist. Over time, the small individual “reframes” become thematic, involving many family members, a series of events, and a complex alternative explanation for the problem. As a result, the reframing process helps organize and provide a therapeutic thread to

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the engagement and motivation phase. In fact, the constructed, family-focused problem definition helps organize therapy and becomes the major theme that explains the problems of the family, and thus, manages behavior change efforts.

More recent articulations of FFT have focused on the value of reframing beyond helping reduce negativity and blame in a single instance. One of the important outcomes of successful and ongoing reframing is that a broader explanation of the struggles of the family emerges and functions clinically to create family alliance. In early sessions of FFT, the therapist responds to each family member’s story about the problem by reframing, with the goal to reduce blame and negativity and find the noble intentions in other family members’ behavior. To use a metaphor, when building a snowman in the winter, you begin by making a snowball. You roll the ball over and over, and as you do, layer after layer of (meaning, in the case of FFT) are added to what might be a simple beginning reframing hint. Over time, those reframing incidents begin to form a theme that describes the struggle of an individual, or that of a whole family, in a way that

transcends a single event. As such, the result of reframing is a bit like the theme of a good novel— an explanation that captures the message, sets a specific emotional tone, and suggests a future direction. When successful, family relational themes explain the problem experienced by the family in a way the redefines that problem as one with a family focus (“it’s about us”), identifies each person’s role (“I have a part in this”), reframes the intentions of all parties involved (“the way you did it might not be OK, but I understand the reason why”), in a way that also frames the next steps for the family (“therefore, the next step is to find a way to work out these problems, given the challenges you are each experiencing”). Figure 11.3 illustrates the process of reframing for the purpose of building relational family themes that can form the foundation of the next phase of treatment.

Phase 2: Behavior Change Phase The primary goal of the behavior change phase is to build on the changes in attitude and emotion within the family developed in the previous phase, by targeting and changing specific risk behaviors

Acknowledge & Identify

An alternative idea about the intention … the noble intention

Add the next layer Making it fit the client

Assess acceptability/fit

What did they hear? Did it fit?

Reframe

Impact

Change/continue

The event, behavior, or problem definition

FIGURE 11.2. Relational reframing. From “Functional Family Therapy: Evidence-Based and Clinically Creative,” by T. L. Sexton, in Handbook of Family Therapy (p. 262), by T. L. Sexton and J. Lebow (Eds.), 2016, New York, NY: Routledge. Copyright 2016 by Taylor & Francis. Adapted with permission.

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within the relational patterns of individuals and families through building specific protective skills. These targets frequently include changes in communication, problem-solving, conflict management, and parenting. Changing risk behaviors involves targeting the behavioral skills of family members in order to increase their ability to competently perform the myriad tasks that contribute to successful family functioning. The goals of the behavior change phase are to change individual and family risk patterns in a way that matches the unique relational functions of the family and is consistent with the change obtainable by this family, in this context, with these values.

It is in this phase that much of the recent advances in the FFT model have been developed. In the early years of FFT, behavior change was viewed as a very technical phase and treated in a simplistic way, by providing clients with classes or other resources with which to learn a whole curriculum of skills about communication, problem-solving, parenting, and conflict management. In subsequent years, researchers viewed the stage as one in which therapists taught the skills the family seemed to need. However, through clinical work, FFT therapists discovered that these skills could not be viewed or implemented as a curriculum-based program. Unfortunately, in real practice, families often did not see the relevance of discrete and isolated skills, they could not maintain the skills, and the skills did not specifically fit the specific family or context. Instead, we discovered that individualizing skills to uniquely fit the family and helping apply those skills to salient

issues presented by the family improves engagement and treatment outcome. Each of the relatively simple targets of change needs to be uniquely crafted to fit the relational functioning of the particular family in treatment.

As a result of these observations, we now empha- size teaching skills in a way that is relevant to families (see Figure 11.4). From the family’s perspective, the most relevant task is to successfully work out the problems that they encounter each day. Thus, the behavior change phase of FFT is now organized around helping families to problem solve or negotiate issues in daily life as a central feature. This approach prioritizes problem-solving as a primary skill that can be aided by additional skills of conflict management, communication, and alliance-based parenting. This might mean that in one family, problem-solving may also focus on the communication issues inherent in solving a problem. In another family with a different relational profile, the same problem-solving approach may instead have a greater emphasis on conflict management so that the focus on solving issues does not get derailed.

In addition, FFT therapists have become aware that skills need to be matched to the relational functions of the family relationship. For example, in some families, the same communication principles would look more disconnected and distanced, with information exchanged via notes instead of conversation. In another family with a different relational function profile, communication change may take the form of close and connected negotiation of changes, so that all family members feel connected

Listen to the response of

the client and add to the

reframe

Reframe blame, negativity, or a problem definition reported or exhibited

Build a relational theme to explain the issues in the family that includes everyone and their challenge

Include others in the growing

reframe

FIGURE 11.3. Building relational themes through reframing.

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and part of a collaborative relationship with one another. Therefore, the goal of FFT behavioral intervention is not to change the relational functions of behaviors but instead to change the manifestation of these functions. By focusing on the expression of functional outcomes, not on the outcomes themselves, FFT individualizes changes of behavior to fit the existing relational functioning of the family, while at the same time respecting and honoring the core nature of the unique family. Making behavioral technologies fit the family relational system allows the family therapist to take the path of least resistance.

Phase 3: The Generalization Phase In the generalization phase, the focus of attention turns from changing family behaviors to extending the application of these changes to other areas of family relationships and helping empower the family to manage their future. It is in this phase that a number of other advances have been made in the FFT model. In the earlier articulations of FFT, the generalization phase was viewed as one in which the therapist took the role of a case manager. In a sense that is still true, insofar as the therapist needs to step

back and turn more and more responsibility over to the family. However, current research suggests that successfully empowering families requires specific and purposeful attention to promoting systematic relapse prevention and comprehensively generalizing skills to new contexts. Thus, the most recent version of FFT places relapse prevention interventions as central in this phase.

In this phase, primary therapeutic attention is on the family’s interactions with the external world. Once again, the therapist accomplishes the phase goals by engaging in discussion of salient issues for the family with three primary objectives: to generalize the changes made in the behavior change phase to other areas of the family relational system, to maintain changes made in the generalization phase through focused and specific relapse prevention strategies, and to support and extend the changes made by the family through incorporating relevant community resources into treatment. The desired outcomes of the generalization stage are to stabilize emotional and cognitive shifts made by the family in the engagement and motivation phase and reinforce

Alliance-Based Problem-Solving/Negotiating

working things out

Communication

Collaborative Conflict

Management

Using principles of positive communication and matching

responses

Alliance-Based Parenting

monitoring and supervising

FIGURE 11.4. Relational skills in behavior change phase.

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the specific behavior changes made to alter risk and enhance protective factors. This is accomplished by having the family develop a sense of mastery around its ability to address future and different situations.

During therapy, clients build a growing sense of perceived control over situations that were previously marked by anguish, anger, negativity, and blame. With each subsequent success, the individual and collective family perception of self-efficacy grows. This upward spiral continues until the family or a family member experiences a high-risk situation that poses a threat to their perceived control, decreases self-efficacy, and eventually increases the probability of relapse. Conversely, when a family member copes effectively with a high-risk situation, he or she is likely to experience an increased sense of self-efficacy. As the duration of new behavior increases, families have the experience of coping effectively with one high-risk situation after another, and the probability of relapse decreases significantly. However, failure to master a high-risk situation is likely to create decreased self-efficacy and a sense of powerlessness. At that point, a relapse is likely. If a slip does occur, it is not uncommon to experience a sense of cognitive dissonance that may promote the adoption of more individual blaming attributions, increasing the likelihood that a full-blown relapse will occur. Relapse prevention helps to make the changes accomplished in therapy part of a new interactional pattern that can resist future challenges, resulting in a relational stability that will maintain new and healthier behaviors.

Throughout the generalization phase, the FFT therapist focuses on the family’s ability to generalize skills as well as support and maintain skills in new contexts. More specifically, the therapist encourages the family to demonstrate their ability to manage daily problems. Successful FFT families are not families without problems. Instead, they are families that are able to continue using skills over time; handle more and different problems; be consistent; adapt and adjust when problems arise; and address other, larger concerns they face with peers, school and other community issues, legal requirements, and/or extended family challenges.

EVIDENCE-BASED TREATMENT PLANNING: THE FUNCTIONAL FAMILY THERAPY CLINICAL FEEDBACK SYSTEM

Recent research on the role of therapist adherence, along with our clinical awareness regarding the diversity and uniqueness of families and the problems they face, has led us to believe that therapists need more than models and intervention techniques to be successful. In real-life clinical settings, clinicians must make decisions regarding how to best adapt treatment to the needs of clients they serve, in every interaction they have with a family. To do so, clinicians must be able to evaluate whether a client is improving, remaining stable, or deteriorating. Each level of decision making requires a different type of information and a different process for using that information in clinical work. Even the most skilled, trained, and experienced clinicians will make better decisions when they use current, real-time information. This process is one of individualization, or working with precision.

Evidence-based treatment planning is central to the practice of FFT. FFT has developed a set of treatment planning tools, a web-based computer system, and a decision-making process to help therapists integrate their own reflections and client feedback. FFT-Care4 is an online web-based system that integrates an existing battery of process, progress, and case planning measures (for youth symptoms, family functioning, session impact, and progress). The FFT-Care4 system is composed of three components: (a) clinically sensitive measures that are administered regularly throughout treatment to collect ongoing information concerning the process, (b) progress of treatment, evaluated using timely and clinically useful feedback from the client, and (c) treatment planning tools to organize and focus the evidence to aid in clinical decision making. The goal of the FFT clinical feedback system is to provide information that assists therapists in clinical decision making, by prioritizing and therefore individualizing the process more quickly and effectively, giving youth and families a voice in treatment that they are safe to express if necessary, providing a multisystemic

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perspective that considers multiple points of view, and offering a way to monitor therapeutic process and progress in real time.

Each week, family members complete short and relevant measures of youth symptoms, session impact, and progress, which are in turn given back to clinicians as feedback through the secure web-based application. The clinician feedback system is based on a “quickly look” philosophy: Clinicians can look at a graphic representation of client progress over time and compare ratings across family members to determine progress and next steps, rather than read extensive reports and text. Feedback is presented through status indicators in three areas (youth symptoms level, session progress, and family functioning); clinical alerts (indicators of immediate need, such as adolescents running away); and comprehensive feedback reports showing change in symptoms, impact of FFT, and progress over time for each family member. This comprehensive and real-time feedback is the basis of the next session plan.

However, good decision making involves more than just information. Decision making is actually an ongoing process, as demonstrated in Figure 11.5. In sessions, clinicians try to make progress through the relational interactions in the therapy room. Following sessions, therapists reflect on and identify which interactions were most important and areas in which progress was made. Next, we ask therapists to look at family member feedback. Finally, systematically combining the judgment of the therapist with the client feedback forms the plan for the next session. In this process, all of the critical components of treatment planning are included: the judgment of the therapist, the feedback from the client, and the guidance of the treatment model.

SCIENTIFIC FOUNDATIONS

The cumulative evidence spanning over 30 years demonstrates that FFT can, when implemented correctly, result in positive outcomes in many settings and with a range of clients (Alexander et al., 2000; Sexton, 2010). The research supporting FFT is community based, of high methodological quality, carried out with real youth (e.g., multiproblem, ethnically diverse, with a wide range of socioeconomic

status) in real settings (e.g., home, community), and implemented by community-based professionals with diverse training backgrounds. These studies led the Center for Substance Abuse Prevention and the Office of Juvenile Justice and Delinquency Prevention to identify FFT as a model program for both substance abuse and delinquency prevention (Alvarado, Kendall, Beesley, & Lee-Cavaness, 2000). Similarly, the Center for the Study and Prevention of Violence designated FFT as one of the 11 (out of over 1,000 reviewed) Blueprints for Healthy Youth Development programs (Alexander, Pugh, Parsons, & Sexton, 2000). Such designations are based on the fact that FFT has demonstrated outcomes in many settings and with many diverse clients.

Because FFT has been in existence for decades, the initial research supporting its efficacy is relatively old. The initial study of FFT was conducted by Alexander and Parsons (1973). At 6- to 18-month follow-up, the reoffense rate for youth treated with FFT was 50% lower than that for the other treatment groups (26%, compared with 50% for no-treatment controls, 47% for client-centered family group therapy controls, and 73% for eclectic psychodynamic family therapy controls). The study also established that FFT had an impact on communication patterns and within-family communication. Klein, Alexander, and Parsons (1977) published a follow-up study and found that siblings in the families that received FFT (in Alexander & Parsons, 1973) had only a 20% post-FFT court referral rate. These findings suggested that FFT had not only a significantly greater impact on relatives (compared with a reasonable alternative treatment) but also an absolute effectiveness (compared with no treatment) on siblings who were not even the primary focus of attention in treatment. Gordon, Arbuthnot, Gustafson, and McGreen (1988) and Gordon, Graves, and Arbuthnot (1995), using a model of FFT that emphasized problem-solving and specific behavior change skills, found FFT to result in much lower rearrest rates at both 24 months and 5 years posttreatment. Compared with juveniles who received regular probation services, of whom 67% recidivated, those in the FFT group had an 11% recidivism rate at 2-year follow-up. Waldron et al. (2001) studied the impact of FFT with

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FIGURE 11.5. Evidence-based treatment planning.

Clinical Decision MakingTreatment Session

Clinical Feedback

ONGOING TREATMENT

-treatment goals & progress -client reports (symptom level,

weekly impact, progress)

Therapist Input (Progress Notes)

-Assessment -Anticipated Session Goals

-Observed Session Progress

Session (type of session/

contact/time/treatment phase)

Individualized Next Session Plan

updated treatment goals adjusted session goals technique adjustment

Family & Youth reported

Symptom Severity

Family & Youth reported

Treatment Progress

Family & Youth reported session Impact

to... Individualize and fit the family better

to improve implementation of FFT

Family Input Youth & Caregiver reports on:

-youth symptoms -impact of therapy

-perceived progress

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drug-using youth. Combined treatments showed significant reductions in percentage of days using marijuana from pretreatment to 4 months following initiation of treatment.

More current studies have also identified FFT as an effective intervention in real-life community-based contexts in the United States and other countries. The largest study of FFT was conducted in the state of Washington and was the first to study FFT in a true community-based setting. When compared to a no-treatment control, the FFT group had a 31% reduction in criminal behavior and a 43% reduction in violent recidivism. However, the positive effect of FFT was not universal. Whereas the clients with therapists who delivered FFT with high fidelity (i.e., adherence to how it was designed) had the outcomes noted above, clients of therapists who did not deliver the model with high fidelity had outcomes that were worse than those for youth who received no therapy at all, but instead were merely supervised by their probation officer (Sexton & Turner, 2010). This finding suggests that quality assurance and implementation plans are a critical feature in successful community implementation.

Recent European FFT studies found similar positive outcomes of FFT. The first, conducted in Ireland, was a retrospective study of FFT’s effectiveness; findings suggested that adolescent behavior problems improved in cases treated with FFT and that the greatest improvement occurred in cases treated by therapists who implemented FFT with a high degree of fidelity. For the 98 treat- ment completers, findings showed significant improvement in conduct problems, hyperactivity, emotional symptoms, and prosocial behavior scale ratings. After an average of 17 weeks of FFT, approximately 40% of the 98 case patients had clinically recovered and scored below the clinical cut-off point. The best outcomes for various areas of mental health occurred when treatment was administered by therapists who conducted FFT with a high degree of fidelity (Graham et al. 2013). In a second randomized trial (Hartnett, Carr, & Sexton, 2016), the dropout rate was only 7%, compared with the control group. The families who participated in FFT reported significantly greater improvement in adolescent conduct problems

and family adjustment, and improvements shown immediately after treatment were sustained at 3-month follow-up.

CONCLUSIONS: CREATIVITY WITHIN THE STRUCTURE OF FUNCTIONAL FAMILY THERAPY

As a treatment model, FFT has grown, developed, and evolved over 30 years. It progressed from being a theory to an evidence-based clinical treatment program that now includes evidence- based treatment planning, clinical feedback systems, and systematic ongoing measurements of clinical process and outcome. FFT provides a systematic and comprehensive way of thinking about how clients function, about the etiology of clinical problems, and about how to provide the most effective and efficient pathway to helping families change. As a mature clinical model, FFT has developed all of these features along with corresponding tools with which to do evidence- based treatment planning. As family members tell their stories, the therapist must respond in a personal yet therapeutic way, taking every opportunity to purposefully respond in order to meet the phase-based relational goals of the model and help to move therapy forward. If someone were to observe from the outside, FFT would appear to be similar to a conversation: an ongoing discussion in which family members describe their struggles, experience related emotions, and help to change their own situations. It is the job of the therapist to turn these discussions into mechanisms for positive change. At the end of the day, the creativity of the therapist helps translate the concerns and problems presented by the family into the FFT model process in specific and relevant ways.

The FFT model is designed to aid that creativity. FFT is the structure within which the expert develops systematic and complex case conceptualizations; it provides a reliable and clinically relevant way to understand clients, problems, and context. The FFT model contains both the knowledge and procedural structure that form the scaffolding of a therapist’s expert judgment. It is this scaffolding that forms the structure within which cases are

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conceptualized and forms the foundation of how “in the room” decisions are made, while also providing a road map of the steps to take to promote successful change processes. The model establishes a way to integrate case conceptualizations, core skills, and contingent—yet model-specific—clinical decisions. It organizes the vast array of information gained from clinical experience into meaningful and usable principles that have clinical utility. It gives the therapist the ability to know what the goal is, the most reliable and valid ways of accomplishing that goal, and a way to judge whether adaptations or variations need to occur. Ultimately, the FFT model helps navigate the difficult, emotional, and challenging tasks of successful family therapy.

The development of FFT has paralleled that of other approaches in the field of family and couple psychology. Despite significant research and a wealth of conceptual and theoretical models, family and couple psychology continues to search for common principles and clinical interventions that are viewed as reliable and valid across various clinical problems, contexts, and client groups. As the field has moved from theoretical models to evidence-based practices, practitioners have continued to struggle with trying to find their individuality within specified models, training programs have struggled with how best to teach new and evolving ideas, and researchers have tried to find ways to study both the effectiveness and the art of family and couple psychology. As the field continues to evolve, we are likely to find new pathways that integrate the knowledge gained from both research and experience. Technology is likely to play an important role in this evolution, providing new sources of information for practitioners and new ways to bring clients’ voices into treatment through measurement feedback approaches. The future holds the promise of not only more diverse and more effective evidence-based treatments, but also innovative ways to practice each session using relevant real-time evidence.

The future of FFT is likely to follow its steady developmental path—changing as new evidence, ideas, and needs emerge from the field. One example

of potential evolution is in some of the new adapta- tions that have recently been developed. Sexton and Kelly (2016) have developed an adaptation of FFT for use with children and adolescents in foster care. Sexton and Kelly (2016) are now piloting a trauma informed version of FFT (FFT-Sanctuary). There is also a future need to study implementation of and training in FFT. For example, Sexton and colleagues are now testing online methods for cost-effective and evidence-based training. Future research needs to focus on further articulation of the clinical change mechanism within the model to better know how to individualize treatment to diverse families. As both new clinical areas and new mechanisms are identified and incorporated into FFT, it will retain its constant systemic and evidence-based focus on each.

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