moving toward the end: behavior change and generalization clinical training 3 thomas l. sexton, ph....

Moving toward the end: Behavior Change and Generalization

Clinical Training 3

Thomas L. Sexton, Ph. D., ABPPFunctional Family Therapy Associates

Goals

1. Matching…..2. Generalization phase3. CFS in Clinical Decision making4. and…..

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?

What does successful FFT require

Delivers FFT with Adherence & competency

6 month 12 months 18 months0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Adherent Non-Adherent Control

• 38%* reduction in felony crime

• 50%* reduction in violent crime

• $10.67 return for each $1

invested

• $2100 perfamily cost to

implement

Family Reality“alliance/outcome issues”

Life Expert

•Experience in the room• how do I feel about….?• how does this fit with

what I think about…• does this make sense to me?• what does this mean I will

have to do?

•Process Focus• what phase am I in?

• what are the goals of the phase?• what do I need to assess?

• how do I need to intervene • to accomplish the goal• how do I “match to…..”

• what do I need to know about…...

Therapist Reality“process issues”

Change Process Expert

An example: Lilly

• 14 years old

• Referred by juvenile justice system• Pulled a knife on her mother

• Marijuana

• Expelled from school

• Runaway

Clinical Symptoms/Behaviors

Family Relational System

Ecosystemic SystemPeer/school/community/extended family

Ecosystemic SystemPeer/school/community/extended family(Sexton, 2010)

The Multisystemic Focus of Functional Family Therapy



Court system involvement

SchoolStruggles

Family changes (joining John’s fmaily)

Peer GroupPressure

Invovement


Family Relational Pattern



Youth DefianceDrug Problems

DepressionViolent Behavior

Lilly-responds defiantly

MOM-gets worried

-asks (indirectly)

MOM-jokes, makes fun -tries to get her

to “do it for me”

LillyObviously irritated

-blows off Mom

MOM-hear it as “she doesn’t care”-gets scared



MOM-gets angry

-lectures-withdraws

MOM-gives a

consequence(sever and non specific….takes

away

Lilly-Esclates defiant

response-

When it is a serious even

MOM-esclates control

When it is a serious even

Lilly-Esclates defiant

response-exhibits

additional When it is a serious even

Mom/mother figure

Dad/father figureAdolescent

Problem “definitionI have done nothing wrong…

what I did was a mistake and wont’ happen again-the problem is you won’t leave me alone

-you took everything from me and there is no reason to try

Emotional Reactions (negativity)

-anger-hurt

-fear of loss of mom

Behaviors-her role in the problem sequence

Problem “definitionI have done everything I could

I can’t take it because-she is unwilling to work with me

-she might have MH problems (depression)

-her defiance is the problem-the solution is to “control”

Emotional Reactions AngerHurt

Fear of loss of control

BehaviorsHer role in the problem sequence

Relatedness Assessment

Mom

Adol

Dad

42

1

13

3

Mom

Adol

Peers

3

3Biologi

cal Father

?

Reframing

• Identify the Behavior(s) (from problem definition)• (mom): Lilly’s defiance is…..

• (lilly): Mom’s controlling is…..

• Acknowledge the importance of each to the person (link their struggle with something important to them)

• ReframeLilly’ defiance is….

Strong willednessFear of changesProtection of herselfFear at losing Mom

Mom’s controlling is…

Fear of losing her daughterProtecting herStruggling with her own perceived inadequacies

MOMProblem “definition

I have done nothing wrong…what I did was a mistake and wont’ happen again

-the problem is you won’t leave me alone-you took everything from me and there is no reason to try


-anger-hurt



LillyProblem “definition

I have done everything I couldI can’t take it because

-she is unwilling to work with me-she might have MH problems

(depression)-her defiance is the problem-the solution is to “control”




Organizing/Relational Theme

• Explaining the problem in relational Terms• Involves every one• Identifies the struggle in descriptive way • Identifies the noble intention• Identifies the challenge of each

• Them…..“given all that has gone with you gwo….both have come a point where your afraid losing each other….That is hard to see given the behavior…..but behind that is this fear…..

• Mom….when you are controlling…..really trying to protect your daughter….(maybe not protect way…maybe other ways to protect….but that is the motivation…

MOMProblem “definition

I have done nothing wrong…what I did was a mistake and wont’ happen again

-the problem is you won’t leave me alone-you took everything from me and there is no reason to try


-anger-hurt



LillyProblem “definition

I have done everything I couldI can’t take it because

-she is unwilling to work with me-she might have MH problems

(depression)-her defiance is the problem-the solution is to “control”




• Lilly…..

• Dealing with life being turned upside down…..struggling with the changes…and having a hard time finding her way in that….

• Defiance….is kind wird and strange way of dealing but…..it does protect her….and it does help hold in some whay to her mom…(and she of course do that different…and, not smart way…) but, is fear of loving you…..

Discussion focused on:-drug use-defiance

Conflict Management

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

Targets of FFT Behavior Change

Problem Solving

Behavior Change Targets

1. Is it Relevant?• What would feel to the family like success

• What make a “difference”

2. Is it Obtainable?• Can they do it

• Will it derail therapy because it is to hard now

3. Does it “fit” them• Relational functions

• Organizing them

• Lilly BC 1

• Lilly BC 2

Generalization

Phase Based Treatment Goals:

1.Generalize2. Maintain3. Support

Intervention

Assessment

Generalization

Late

Outcomes• Increase behavioral competency of all/family

•Consistent performance of competency in “real” problem situation

Generalization Phase

Shifting Focus for the Therapist

• focus of therapy moves from inside the family to the “interface” between the family and those systems that surround it.

• It requires a shift in direction for the therapist in regard to clinical assessment and intervention. • respond to the “events” in the family with a primary

goal of helping them become ultimately self-sufficient and empowered in their interaction with the surrounding context.

• Shift attention away from helping the family solve immediate problems to a discussion about the role of peer, school, and extended family and community interactions as they relate to the family’s ability to continue reducing the probability of future problems.



The Multisystemic Focus of Functional Family Therapy


Family Relational System

Why the Generalization phase

families take two “steps” when making changes that are lasting:

1. Families change the relational interactions and adopt alliance-based skills in their daily interactions.

2. Families bring this same attitude and skill set to other naturally occurring issues that confront the family.

• In this step, the successful family becomes consistent over time and learns to handle the emotional discouragement of “relapses.”

Logic of Generalization

• small changes can have a multisystemic effect

• These changes often don’t happen naturally

• Specific strategies for generalizing new skills, maintaining change, and supporting those changes with the aid of informal and formal community support systems helps create the necessary system change for long term success.

• Reduces:• Revolving door of treatment• Relapse• Future positive changes

Avoiding the Revolving Door Syndrome

The generalization phase is intended to avoid the familiar phenomenon of the “revolving door” syndrome

• Each time a family receives services they learn to depend on that organization or person as a “needed resource.”

• What they don’t rely on is their indigenous environment of community, extended family, and friends as a source of natural, reliable, and effective long-term interdependence.

Avoiding the Revolving Door Syndrome

• When caught in the revolving door syndrome, the family is inadvertently robbed of the opportunities to learn to access appropriate support systems.

• They don’t build new skills or adapt those gained in earlier phases of therapy,

• and they feel little sense of efficacy or confidence in their ability to manage problems independently.

• “Give a man a fish and you feed him for a day; teach him to fish and he feeds himself for life.” • “learn to dig for the bait” so that they can have the

resources necessary to be self-sufficient in managing the normal challenges of family life.

Generalizing Change

Primary Target

Area/content focused on:

-homework, going out with peers, etc.

New area

New area

New area

Behavior ChangeBuilt a “competency” to

reduce a risk pattern-communication/problem

solving/ etc.

Move competency to a new “content” area

Move competency to a new “content” area

Going outWith friends

Homework

RelationshipWith sibling

Time withboyfriend

Discussion focused on:

How to maintain, support, and

generalize new climate, alliance, behavior changes

Medical Evaluation

Psyc Intervention

Community/School-direct and concrete

communication

Extended Family-monitoring and supervising

Parent Adolescent

Area to support changes, add to

changes, and places to generalize and extend change

Supporting Change

Support Change…resources in community

• Families are multisystemic• Context will impact ability to support change in the long

run

• Examples:

• Parenting class

• Individual therapy

• Rent assistance

• Special school program to help with academic issues

• Goal:

• Have the FAMILY do it….you help direct them

• Becoming self-sufficient in using relevant/necessary community resources to help

• Using behavior change competencies to deal with the world around them

Types of Social Support

• Instrumental support (i.e., financial assistance, help with transportation, and parenting assistance)

• Emotional support (i.e., empathy, and caring)

• Informational support (i.e., help finding the best prices on food, need-based school assistance, or places to get rent and utility assistance).

Maintaining Change

• Change process is a up and down experience• Often the down feels as if it is a failure

• Goal is to reframe it as a “normal” experience in the change process

• The goal….despite the current failure/discouragement to begin the behavior changes again

• Build confidence/efficacy in their ability to maintain changes….by:

• Attribute change to the family

• Responding to events they bring in by focusing on relapse prevention

Relapse Prevention

Successful relapse prevention requires that the therapist take the initiative and direct a discussion that helps to:

• Identify high-risk situations. • The discussion should include an analysis of the

cues, initiating situations, family conflicts, and patterns of high-risk situations that may undermine the family’s ability to continue with their established changes.

Relapse Prevention

• Learn alternate ways to respond. • The behavior change strageties they learned

• These include identifying ways to:

• cope with the negative emotions that arise around these situations, both for individual family members and the family as a whole;

• determining ways to deal with interpersonal conflict by applying conflict management principles; and

• discovering strategies to cope with social pressure that may result from both proximal and distal support systems.

Outcome of Generalization Phase

When successful the family:

• attributes the change to their effort

• is realistic about future struggles

• has a plan for how to continue to apply what they have learned to new situations

• continue to maintain a within-family alliance and a view of the family based on the organizing theme developed early in therapy.

What is enough change?

• When do you end?• What does the say?• What specifically to look at?

• What gets in the way of ending?• What are your barriers?

What are you looking for in the families?

• Keep it up

• What they need is to find a way to continue the changes they made in therapy despite new problems, the return of old issues, or other risk factors that may get in the way.

• This most likely to occur if they know:

• where to apply skills, what to bring to discussions (family focus and alliance-based perspective), and

• how to continue with the “organizing theme” and direction built in the engagement/motivation and behavior change phases.


• Handle more and different problems

• From the family’s perspective, new problems have the tendency to look different.

• The more skills that the family needs to employ, the more the chance of success goes down.

• Instead of getting endless new lists of skills expand their existing skills to new problems in a way that seems manageable.

• They will be most successful if they can apply the small steps of behavior change to an increasingly wider range of issues in daily life.


• Be consistent

• There will be times and situations where despite their best efforts, things will be a struggle.

• They will be most successful in overcoming these situations if the family focus and behavioral skills are attempted and maintained, regardless of their total success, in situations through time.

• By this means, they would overcome the natural discouragement of the ups and downs of change.

• One of the most difficult parts of keeping things up are the competing “pulls” clients feels from the world around them


• Adapt and adjust when things come up

• It is not uncommon to see the specific change strategies used in FFT evolve as the family uses them.

• Families tend to come up with unique family-based, alliance-based solutions that include social skills that fit into the protective factors category.


• Address other bigger issues • Families continue to face risk factors • Address those proactively

• Peers• School & other community issues• Legal requirements• Extended family challenges


• Be realistic

• Holding the realistic belief that positive change is possible and they do have the ability to succeed is important.

• The belief needs to be realistic, not one that sets them up for failure by being too positive.

• If the belief includes knowing that things will happen again, that it won’t be fun, but, with effort, there is an alternative, which creates the motivation to initiate new behaviors and put effort into persisting at them.

moving toward the end: behavior change and generalization clinical training 3 thomas l. sexton, ph....

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