The California Institute for Mental Health

FUNCTIONAL FAMIILY THERAPY (FFT) SYMPOSIUM

April 28 – 29, 2010Sheraton Gateway Los Angeles Hotel

“The Core of FFT”

James F Alexander, Ph.D.University of Utah & FFT

Happy Birthday Mary

The Core of FFT

What is our “essence?” …

Our “character?” …

Our “mission?” …

What do we do? …(Actions speak louder than words!)

The Core of FFT (2)• Think “comedy”

• What is good comedy? What makes comedy “work?” Do we even “need” good comedy - or art or music or

poetry or fiction or sports and recreation for that matter?

• What does it take to create good comedy? Good art? Good fiction? A 2.42 ERA? A beautiful mural on a building in downtown LA? A meaningful mural on a

building in downtown

• Can everyone do it? - NO!

• Can we afford for only the “special few” to be able to do it? - NO!

The Core of FFT (2): What Is FFT?• First, FFT is a person – a person “doing” FFT √

• FFT is a “model;” a framework, a way to “think” and plan, and a guide or map with steps about what to do and when to do it √

• FFT also is a “model,” or framework, for training, monitoring, and maintaining quality > effectiveness; It is a system with feedback and internal correction built in, which also is available to others (yep – the old/new “transparency” thing ) √

• Doing FFT well is determined if not defined by our (and our client families’) ethnicity, religion, gender, social class, political beliefs, intelligence

… NOT !!!! …Influenced by? …. Yes. But determined by? NO!

• Doing FFT well is determined, if not defined by, our attitudes, our beliefs, our passion, our “heart,” and our stubbornness √

(selective! )

What Are These Beliefs? • Something about these people can change

• And I can do something to help that change to go in a positive direction

• I will do a better job if I follow a plan, a “model,” which has been shown to be effective (“efficacious”) with very troubled families often with great challenges like the ones we see

• I (yep, us …. Not just the families) am better off if I do this right!

(Not “make,” “force,” “insure,”)

Someone is watching, and cares!

Oh Yes …. And Then There is the “Doing” Part!

• “Style”– Relational / interpersonal sensitivity, ability to do what is

“right” for the other (not just what is “right”). (R&R: READ& REACT)– And to do it in a way that “matches”

• “Respectful” in a way that they experience as respectful and appropriate - for them!

• Reaches out to them in the domains in which they “live” / exist, can experience productively, and function:

• Specifically, “match” them in terms of “where they are”– Affect, Behavior, Cognitions (ABC’s)

» Centro De La Familia family based Gang Prevention program for girls» Fathers? (Directors’ attitudes & gender preference)

• And “Substance”– Techniques …. Embedded in Phases …. And with structuring skills

GENERALIZATIONGENERALIZATION Eco/Multi- Eco/Multi-

systemic systemic Linking Linking

BEHAVIOR CHANGE

Sessions1 2 3 4 5 6 7 >>>> End

ENGAGEMENT

Pre-Treat-ment

Post-Treat-ment

Note that E & M can co-occur / blend

Note that BC & GEN can co-occur / blend

FFT Phases ( Core Model)FFT Phases ( Core Model)

MOTIVATION

Note that E&M & BC are essentially

sequential

GENERALIZATIONGENERALIZATION, , Eco/Multi- systemic Linking Eco/Multi- systemic Linking

BEHAVIOR CHANGE

Sessions

Pre-Treat-ment

Post-Treat-ment

FFT Unique Components and FFT Unique Components and Phase Strategy Phase Strategy

MOTIVATION

RelationalAssessment&

Matching

ENGAGEMENT

MOTIVATION

Within Family Alliance (Factor 1: Collaborative)As A Predictor of Completion / Dropout

(Freitag & Alexander, 2010)

Mea

n Al

lianc

e

Session-Segment

GENERALIZATIONGENERALIZATION, , Eco/Multi- systemic Eco/Multi- systemic Linking Linking

BEHAVIOR CHANGE

Sessions

Pre-Treat-ment

“ “Generic,” Major Syndrome Specific,Generic,” Major Syndrome Specific,** or Context Specific or Context Specific**** Matching & Techniques Matching & Techniques

*Adol Substance Abuse, Adol PTSD, Sex Offender, Gangs, “mental *Adol Substance Abuse, Adol PTSD, Sex Offender, Gangs, “mental health”health”

**Child Welfare. Integrated Reentry**Child Welfare. Integrated Reentry

Post-Treat-ment

MOTIVATION

RelationalAssessment&

Matching

ENGAGMENT

MOTIVATION

The Complete FFT Dissemination Model Phases

PretreatmentPretreatmentSystem Integration System Integration

PhasePhase

PosttreatmentSystem Integration

Phase

FFT CW Direct TreatmentFFT CW Direct Treatment PhasesPhases

- - EngagementEngagement- MotivationMotivation- Relational > BehavioralRelational > Behavioral AssessmentAssessment- Behavior Change- Behavior Change- Generalization / Ecosystemic - Generalization / Ecosystemic Integration Integration

The Youth / Family “Management” or Support System(s): The Youth / Family “Management” or Support System(s): Child Welfare, Mental Health, Justice, Drug Court, Welfare, EducationalChild Welfare, Mental Health, Justice, Drug Court, Welfare, Educational

Boosters, Boosters, Maintenance of Maintenance of links w/ Youth links w/ Youth Mgt Systems, Mgt Systems, Positive closePositive close

Referral, Preparation,Pretreatment

Linking w/ Youth Mgt

Systems

* Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001 * Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001

AssessmentAssessment AssessmentAssessment AssessmentAssessment

Assessment by Phase - Generic

PretreatmentPretreatmentSystem Integration System Integration

PhasePhase

PosttreatmentSystem Integration

Phase

FFT CW Direct TreatmentFFT CW Direct Treatment PhasesPhases

- - EngagementEngagement- MotivationMotivation- Relational > BehavioralRelational > Behavioral AssessmentAssessment- Behavior Change- Behavior Change- Generalization / Ecosystemic - Generalization / Ecosystemic Integration Integration

The Youth / Family “Management” or Support System(s): The Youth / Family “Management” or Support System(s): Child Welfare, Mental Health, Justice, Drug Court, Welfare, EducationalChild Welfare, Mental Health, Justice, Drug Court, Welfare, Educational

Boosters, Boosters, Maintenance of Maintenance of links w/ Youth links w/ Youth Mgt Systems, Mgt Systems, Positive closePositive close

Referral, Preparation,Pretreatment

Linking w/ Youth Mgt

Systems

* Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001 * Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001

AssessmentAssessment AssessmentAssessment AssessmentAssessment

Evaluate Risk &

Protective Factors for

Triage; Assess already involved systemsRelational

Functions, Deficits &

strengths, safety & initial

treatment challenges

Skill deficits & challenges, short

and long term change goals (Behaviors, Emotions, & Cognitions)

Extra-family & Multiple system

challenges & positive

resources

Syndrome-Specific Specialization vs Syndrome-informed EM, BC, & Gen

• Adolescent substance abuse / use, Adolescent PTSD, Adolescent Sex Offender, Child Welfare, and Integrated Reentry all represent syndromes and contexts commonly encountered by many FFT therapists.

• As a result, FFT therapists responsible for the larger range of FFT referrals will be provided as many FFT-specific tools (knowledge & techniques – but only within their “scope of practice” abilities & training) as possible as we move into increasingly diverse treatment contexts.

• However, these syndromes and contexts also can represent specialty training tracks offered as packages to specific treatment systems (e.g., institutions with reentry / “aftercare” treatment responsibilities; Drug Courts, Child Welfare Systems, Mental Health systems specializing in PTSD, Dual Dx Depression / Anxiety). In this case, FFT therapists will be trained as teams providing specific FFT “packages.” This training will be more extensive, and will require manualized and evidence-informed versions of FFT, primarily during Behavior Change.

GRYD Risk & Protective Factor Domains (“Ecological Model”)

Youth

Family

Community, Neighborhood

Institutions

The Moment of Decision – Proximal and Distal Influences

Youth

Family

Community

Institutions

Peers?

The Moment of Decision: Proximal Influences

Youth

Family

Community

Institutions

Peers?

Attachment issues, Internal

sense of “security”

Identity, “Self Concept”

Behavioral Styles & Patterns, Skills

Self Regulation (self soothing,

emotional intelligence,

impulse control

“Internal” Representation of

Family, Community Peers, “Institutions” Biological Risk &

Protective Factors

The Moment of Decision: Proximal Influences

Youth

Attachment

“Self Concept”

Behavior Patterns, Skills

Self Regulation

“Internal “Representations of

Others

Biological R & P

Cancer Staging (as a metaphor) •Stage 1: Usually cancer is relatively small & contained ; seemingly easily treated “non aggressively”

•Stage 2: The tumor is larger than in stage 1 ... Sometimes spread into lymph nodes.

Aggressive Tx necessary, but with high long term outcomes

•Stage 3: cancer is larger ...started to spread … ...cancer cells in the lymph nodes in the area

• •Stage 4: cancer has spread from where it started

to another body organ. Very aggressive interventions necessary, but with low “success” rates nonetheless

Gang “Staging”•Stage 1: Risk / Protective factor ratio is low; seemingly easily treated “non aggressively;” low probability of gang entry under current conditions

•Stage 2: Risk / Protective factor ratio higher; low but discernable levels of gang-related behaviors

appear; attitudes positive re gangs

•Stage 3: Clear identification w/ gang mentality; aggression > violence; 1 major or several less serious but notable criminal behaviors;

•Stage 4: Major gang involvement, high offense rate, few or no protective factors, long duration of

criminal behaviors, violence and/or heavy economic integration.

What Are The Risk Factors? (GRYD)• Youth (10-15), four or more risk factors, highest risk

• Antisocial Tendencies– Isolates self, Unable to work as part of a socially acceptable group – Rebels against authority

• Impulsive Risk Taking– without first considering potential consequences. (“Impulsivity”)  – experience s dangerous or illegal acts as thrilling (“Under-arousal?”) 

• Neutralization (Rationalization; externalization; no guilt)– Justifies actions hurtful to others, – Consistent victimizing and manipulating others; rationalizing that it

is acceptable– Unable to show or feel remorse or accept responsibility

• Delinquency & Substance Abuse– Frequently involved in illegal behaviors connected to drug use

• Negative Peer Influence & Peer Delinquency– Associates w/ friends directly involved in illegal activities  

What Are The Risk Factors (2)? • Critical Life Events

– a traumatic event – in combination with other risk factors may the “the last straw”  

• Weak Parental Supervision– Lacks parental guidelines – street activities without the knowledge/ supervision of parents.– parents are often physically or emotionally absent

• Family Gang Influence– influential family members active in formal gang activity.– family values that affirm and accept gang involvement as normal

•  • Personal” – ADHD, depression, anxiety, etc ( JFA)Separate “trait” /

genotype contributions from phenotype (contextually elicited & reinforced components.

• JFA Addition – school / vocational involvement; guilt is good, -parents permissive, - do as I say not do as I do. (not as big a problem) – are separate issues

•