Hi this is Dr. Dianne Gehart and this lecture
is on functional family therapy and evidence based treatments for delinquent youth and
their families. This lecture goes with my textbook series,
specifically the Mastering Competencies in Family Therapy text, as well as Theory and
Treatment Planning in Family Therapy. Both are available through Cengage and you
can get the digital chapter by chapter, or in hardback. Functional family therapy is a well recognized
evidence based treatment for working with adolescents who are having conduct behavior
type issues and working with their families. This approach has been widely adopted by many
county and government agencies wanting to work with this difficult population. In a nutshell, the least you need to know
about functional family therapy, it is an empirically validated therapy treatment. What that means is that clinical studies have
very careful studies conducted looking at the outcome, it is a manualized treatment,
it follows a specific outline. That said, it's still going to have areas
where individual therapists will differ in how they deliver it but it is a manualized
treatment specifically designed to work with youth dealing with conduct disorder and delinquency. It is a family treatment. It is one of four widely recognized evidence
based treatments for this very difficult to treat population. All of them basically use a systemic structural
foundation in terms of how they intervene. This approach draws from many of the traditional
system and structural concepts and research has been conducted essentially, on how to
use these traditional, systemic, and structural, and some cognitive behavioral concepts to
help families with youth who are having severe conduct issues. The name of the approach comes from this concept
of looking at the function of the behavior. Just like all systemic approaches, all behavior
is viewed as fundamentally adaptive, that it's serving a particular function in the
system. These kids who were diagnosed with conduct
disorder aren't bad seeds, bad people, instead they see that their behavior plays a specific
function in the system. There are basically two main functions, one
is relational connection. They're looking at whatever the systematic
behavior is, conduct typically in this, and usually acting out conduct behaviors, how
is this affecting the relative balance of closeness and independence in the family? How is the other function it may be playing
is addressing the relational hierarchy. How is it defining who has influence in control
in the system? For example, if you're looking at a conduct
disordered youth who is vandalizing, not attending school, the question is, how is that behavior
affecting the relational connections? Perhaps -- it can go both ways here in terms
of relational connection, there may be an overly involved micro-managing parent and
this behavior helps them to separate from that. Or there can be parents who are checked out
and the behavior forces the parents to step in and connect in some way to parent the child
because they're too checked out. That's what they mean by the function of the
behavior. They're looking to see what the function is
to understand how the teens conduct issues plays a role in the broader system, why it
makes sense in the system. What they're going to focus on is changing
the expression of the function instead of trying to reorganize the system. For example, if we assess the family, we realize
the teen's acting out behavior pulls in otherwise checked out parents, the goal would be, how
do we get this teen to feel like the parents are checked in without having to act out? Without him having to bring the police in
to force the parents to parent him. That would be how they work with this. The therapist's primary task is to identify
the function of these problem behaviors and find alternative ways to achieve those basics
ends without having the severe behavior issues. That's functional family therapy in a nutshell. Next I want to talk about what I call the
juice or the significant contribution to the field. This is one thing that functional family therapy
introduces that is unique that can be used by any therapist practicing in the field. One of the things that functional family therapy
draws to our attention as well as some of the other evidence based treatment for conduct
disorder is the importance of a multi-systemic conceptualization and assessment when working
with, in this case, conduct disordered youth. Working with conduct disordered youth, and
I think it's clear when you look across the evidence based for this population, conceptualizing
it as an individual teen's problem is not the most effective way, according to the research,
to approach this. You really have to look at the individual,
the family, the peer system, the school system, and the broader community system dynamics
and how all these pieces are interacting. When you're dealing with adolescents with
conduct issues, and I would even extend this to younger children too, looking at conduct
issues there is a multi-layered system there and all these layers of systems reinforcing
various behaviors. That needs to be attended to, rather than
conceptualizing this as an individual child attitude issue. It's true with functional family therapy as
well as the several other evidence based treatments for conduct disorder, it really is the focus
in a preferred unit of treatment is the family, not the individual youth. Promoting those strong family bonds, as we
know, is one of the most critical preventative factors that keeps you out of trouble, that
is well documented for decades now. One of the interesting things they have found
is that group treatment of troubled youth together, these are groups for teens who have
conduct issues or "anger issues," this often augments the antisocial behavior rather than
reduce it, which is the a whole other lecture in itself. But I put that out there. In functional family therapy, the therapist
works closely with the youth's school, probation officer, peers, community, extended family,
with everyone who is influential in this child or teen's life, and that's important to really
highlight that working with youth have significant conduct disorder, you just can't sit in your
office, maybe fax out a statement to the school's counselor that you're seeing this kid, call
me if you have any questions. That's not how this works. In functional family therapy the therapist
is very engaged and helping to look at all these different systems and figuring out how
these systems need to be influenced and changed so it can support the youth in having better
life choice and being successful in school, successful with peers, and to be out of the
trouble that is what characterizes conduct disorder. Next we're going to talk about the big picture,
the overview of treatment in functional family therapy. As an evidence based treatment, functional
family therapy has three very clearly defined phases, it has to be a manualized treatment,
similar if you've listened to the focus therapy lectures, that these phases are used to help
guide the therapist as they work with the families where they are and if they're progressing,
get a good sense of what's going on, whether or not the treatment is working. In the early phase there is engagement and
motivation. When you're working with youth diagnosed with
conduct disorders, that's probably the best way to say it, you can imagine that often
the youth, if not the entire family is not happy to be there, they're not wanting to
be in treatment. Resistance, being mandated is very common
issues with this population. It's very important that the therapist engage
the entire family, not just the youth and develop a trusting connection. Oftentimes these youth have been through probation,
been to other counselors and therapists, and often they're very distrusting of the system,
often they've not been treated fairly by the system. That's very important. The second part of the early phase is creating
motivation and motivating all members of the family to do something different. We'll go into detail as to how they do that. Of course in this early phase they're discussing
the function of the problem behaviors. Building relationship, building motivation,
and then also assessing for the function of the problems. The middle phase is where we begin this behavioral
change. Here you're working on modifying, for all
members of the family, their cognitive sets. Typically the parents need to change how they're
looking at things and their attitudes, and expectations, their labels of the child or
each other. You're working with all of them to start looking
both at the cognitive, attitudinal, as well as behavioral changes within the family. Then in the later phase you're generalizing
this change go larger social systems. This can include the school, peers, extended
family, the community. Then you're generalizing in that. By creating these multiple layers and generalizing
the change in the multiple layers of the system you have a better change of therapeutic gains
being maintained so there isn't a relapse in the behaviors. When you're working with conduct disordered
youth it's not just individual, not just the family, you have to look at the entire, broader,
multiple levels of the social system in order to prevent relapse in the future. Next we're going to talk about the therapeutic
relationship in functional family therapy. The therapeutic relationship in functional
family therapy is really critical, as I mentioned before. It's important the therapist have an alliance
with all members of the family. Oftentimes teens and families coming in aren't
coming with a lot of enthusiasm and openness to the process. Often they're mandated by probation or courts
to be there. Oftentimes they've had experiences with other
professionals where they didn't feel heard. They may be very suspicious and untrusting. The family, or the teen, may feel like why
do I have to be here? This isn't going to be helpful, I'm not the
problem. Building that alliance and sense of trust
is critical. You really can't move forward with any type
of therapy, but particularly this approach and client population, building an alliance
with each member of the family is absolutely critical. Similarly there needs to be motivation for
all members of the family to be active in the process. Not just motivating the teen, but the teen's
parents, typically there needs to be change and openness on the part of all parties. The therapist almost expects for clients to
be somewhat reluctant, especially with they're mandated, and they may feel hopeless, the
parent may be feeling blamed, the teen may be feeling fairly blamed. Both parents and the teen can be resistant. The therapist almost expects for by the time
someone is being assigned to a therapist for functional family therapy, by the time they're
in that place, the therapist is well aware that it's not a warm, open reception to the
process. There is a very sincere presence and sense
of respect for all members of the family system as well as a spirit of collaboration. You're going to work with the client in really
valuing their experience, their perspectives. You're going to allow them to create space
to share their side of the story and their experiences. It's very important that both the teen and
all members of the family feel very respected. Oftentimes the parents have been blamed, and
even if nobody has said anything they feel blamed because their child is having behavioral
problems. Another part of the therapeutic relationship
that is important in functional family therapy is that the therapist is viewed as a credible
helper. The therapist needs to have credibility in
the eyes of the family, the therapist can help them, they have the best interests of
the clients at heart, also that the therapist is able to do that. That's one of the things they say comes with
the evidence based treatments, that by using an evidence based approach this helps build
the therapist's sense of hope and confidence. They come across much more as a credible helper. That's an important part of the process. This is a multi-layered, complex, therapeutic
alliance that needs to be developed between the therapist and the teen and the family. It's important that the therapist makes sure
this is solid because it's hard to move forward without having a strong working alliance. Next we're going to talk about case conceptualization
and function in family therapy. Case conceptualization in functional family
therapy begins by looking at the function of the symptoms, specifically the relational
function of the symptoms. What relational function does the symptom
serve? Typically, as I mentioned earlier, there are
two different ways or functions that the symptom, the acting out behavior, the delinquency might
serve. One is addressing relational connection so
the balance between closeness and independence. As I said earlier, acting out conduct issues
could result from parents who are over-parenting, too involved, or it also can result from parents
who are too removed from the parenting of their children, either way. The question is, does that explain what function
the symptom plays in the family. Similarly the relational hierarchy. Who has influence and control? Does the teen's behavior reflect, is the child
trying to establish control over the parent? Is the child trying to resist overly controlling,
too much parental hierarchy for the child's developmental level. The therapist will look at when the child
acts out, how does the family respond? For example, when the child acts out the distant
parent becomes involved because the behavior is so outrageous. Or, is the child acting out to get distance
from the parent? Or, is the child acting out to resist the
overly controlling parent? Or, is the child trying to gain control in
a system that has no control? You're going to look at what function and
how does the family respond to the teen's acting out behaviors. Then the real question is, how can the family
achieve a similar function with more effective relational interactions? How do we achieve the same basic relational
end, which is the parents become more involved or the parents micro-manage less, or the hierarchy
becomes appropriate for the teen's developmental level? How do we achieve that without having the
acting out behavior being the mechanism to make that happen? That is functional family therapy, that is
the crux right there of the case conceptualization. That is the single focus. Everything else is going to be hinged around
that. What's the relational function? How do we achieve that in some other way? Moving on, the therapist is going to look
at risk factors. Determining how to do this you need to look
at both the risk factors and protective factors. There are risk factors in all levels of the
system, the individual child, the parent, the family, the school, the community, all
and all different elements of the community. It could be religious church they're a part
of, a broader neighborhood, a community teen center they're part of, all the different
layers of community would need to be assessed. Obviously, things like violence or even poor
behavioral control, those sorts of things in the teen they would look at, substance
abuse by the teen, or parents, or in the broader community. Looking at emotional, psychological, or educational
problems, has the kid been diagnosed with ADHD before, or depression, or whatever else
might be going on. Is there a known learning disability? Looking at the quality of the parent/child
attachments as well as the quality of the parenting skills. Looking at the teen's choices of friends. Are they involved in after school pro-social
activities, sports, music, anything? Did they used to be? Also looking at the economic opportunities
of the community. Can the parents get decent jobs to support
the family? What's the neighborhood like? Is there violence or gang activity in the
neighborhood? Looking at all of those risk factors. Then the therapist also looks at protective
factors. This is assessing the strengths of the family. Are there bonds and attachment? Is there support of parenting? Is there parenting involvement at any level? Are there clear limits or discipline? You're looking for these types of protective
factors when assessing the family. Even just having one strong, healthy, secure
attachment bond is a real strength that can make a significant difference. The therapist is going to assess for these
things to see how they can leverage this to help move the teen and the family in a better
direction. Case conceptualization and functional family
therapy also, as we've mentioned, includes looking at the multiple levels of systems
involved. That includes the extended family, the school
system, the peer system, there might be a religious church or temple, looking at that
system, the neighborhood, the broader community. You're going to look and assess all that,
the probation system, child protective system if they're involved. You're looking at all those various levels
of system and how they're interacting and relating, looking for both risk factors as
well as the protective factors. Also looking at the community and the culture. How does the culture and/or the community
play a part in the client's life? Looking at that through the multiple layers
of system and assessing for that. Again, looking at any strengths or resiliency,
striving to find a healthy balance between seeing both the client's problems and also
noticing their strengths because the strengths are going to be helpful and critical in the
working phase of treatment. Next we're going to move on to talk about
goal setting in functional family therapy. As an evidence based treatment functional
family therapy has goals by phase. The first initial phase when you're engaging
the family and doing the assessment, you're trying to reduce within family risk factors
which could be substance abuse, lack of involvement. You're also looking to reduce blame and negativity
in the family. Typically there is a lot of blame on the youth
for his behaviors and negativity, this bad kid. One of the things that gets done in the early
phase is reducing the blame and reducing the negative behaviors. Similarly the parents might be feeling blamed
either by the child, society, teacher at the school, social worker, or probation. Trying to reduce blame and negativity for
all members of the family. Also in this initial phase you're working
to increase the family alliances in a family focused view of the problem. Similar to other systemic approaches you're
going to move away from focusing on the identified patient as the one having the problem to looking
at it as an interactional problem, having a family focused view of what the problem
is. The working phase is where you're working
on changing the problem behaviors. You want to increase behavioral competencies
for the family, we'll talk about specific ways of doing that including parenting and
problem solving. Then you're going to match these competencies
to the family's relational function. So whatever function, whether it was the balance
of closeness versus independence in the family, or related to hierarchy, you're going to try
to find ways to use those competencies to match the relational function. Finally in the closing phase you're doing
generalization. You're increasing the within context of protective
factors, so looking for increasing protective factors in all layers of the system, individual,
family, school, broader community. You're generalizing these same principles
and learnings to other areas. So if you learned to problem solve in the
family you're going to learn to problem solve in school, and looking how to support and
maintain gains. Which means looking and working with the multiple
systems involved to ensure that going forward the child and family are going to be able
to maintain their gains. Next we're going to talk about how this gets
achieved through interventions. Developing a family focused problem description. In the early phase you're moving from very
blame focused definitions of the problem to a family focused definition. The family focused definition is going to
help build a sense of understanding, alliance, and motivation for change. First you're going to each family member describe
what they think the problem is, what caused it, and how it's affecting him or her. You'll identify and listen for blaming problem
attributions and then help the family is they see that to begin to see some of the relational
patterns and family structure. For example, the teen may be blaming the parents
for being too controlling and micro-managing. Here's a place where the therapist can reframe
that in terms of, the parents are trying to teach him how to make good decisions, how
to be safe, they're worried about his safety, that's where that's coming from. The teen's defiance can be reframed as, he's
in a developmental phase where he's trying to learn his independence and how to handle
it well. On one hand you've got a teen wanting what's
normal and natural to want more independence, and what's normal and natural for parents
to want their kids to be safe. You can reframe some of that, how they got
into extremes, or whatever you want to say. Again, you're moving and taking both sides
of that, each person's half of the description, half of the problem, making it a more family
focused one and softening the blaming and trying to highlight some of the more benevolent
intentions. Also helping the family to see what these
individual behaviors are part of the larger family interaction pattern. The more the parents are trying to keep the
child safe the more he's resisting because he wants his freedom, he wants to be able
to experiment. Helping to reframe things both in less blaming
ways and more systemic ways, looking at how the more they try to protect him, the more
he tries to be independent and they have this negative downward spiral. Like all system approaches there is an emphasis
on identifying the problem interactional sequence. You're going to look at what behaviors from
all members of the family, not just the main players yelling at each other in the living
room. Who's hiding in the other room? That's also part of the family dynamics. Looking at the different behaviors from each
member of the family, what behaviors come before the problem, what come after? The therapist is also indirectly observing
during session to see what's going on and how people are interacting. Sometimes the therapist asks directly about
that particular sequence to assess it more carefully. Again, they're assessing the problem sequence
is to get a sense of what the function is of the symptom behavior, and how it works
out, and each person's role in that. Another thing that functional family therapists
do is relational framing. It's a cognitive restructuring, helping to
change interpretations and meanings about the problem. They use a three phase process. First they acknowledge the client's experience
and description. There is a validation in that sense. There's a re-attribution. Looking at an alternative explanation for
the same problem behavior. What may seem like controlling, micro-managing,
treatment me like a child behavior, what the teen might describe it, the therapist can
come back and have an alternative explanation where everything parent may be focused more
on safety. Maybe finding a metaphor that implies an alternative
construction. Using various ways of describing this and
also using humor to imply that not everything may be as it seems or as extreme as it seems. He never listens to me. She's always nagging. Using humor to play off of that. She's even nagging when she's singing happy
birthday to you, or whatever it might be. Being playful with some of that. Then assessing the impact of the reframe and
building on it. As you begin to work on this relational reframe
where the parents are trying to keep you safe, how does the teen interpret that and make
sense of that? Continuing to look at not just reframing but
to see what they do with it and then to re-work it in different ways. Maybe the teen still resists that description
or doesn't find it helpful. There may be a major loss the parent experienced
that makes more sense. Again, keep reframing, building on it, to
help all members to have less blaming and a more relational view of the situation. Another intervention they build on organizational
themes. These are themes to help describe the origin
of the problem without blaming any person. These are metaphors and things that a therapist
can continually use to help make sense of the problem in a less blaming and more relational
frame set. Obviously the therapist does not insist on
this but it has to be mutually developed so it's meaningful to everyone and that everyone
is feeling supported. Oftentimes anger can be reframed as hurt or
anger may be implying a sense of loss. Defensive behavior can imply there is an emotional
bond, that's why there's defensiveness. We don't get defensive if we really don't
care about the other person. Nagging can relate to what's important. Pain interferes with listening, differences
can be frightening. Protection can often involve shutting others
out. Playing with these different themes and finding
new ways, relational ways to understand what's going on in a way that people feel less blamed
for the problems. Interrupting and diverting. When working with families with a teen who
has conduct issues there will frequently be conflict in sessions, not always but frequently. It's important that a functional family therapist
be prepared and know how to deal with conflict and actively structure this. This is somewhat reminiscent of enactments
in structural therapy in the sense that the therapist manages a live conflict and sometimes
you'll hear a therapist say, well I want to assess and see what's going on and see how
they argue. Certainly that is not the attitude here. You're not letting conflicts run on without
the therapist actively structuring and intervening, especially given this population. As soon as the family begins to escalate or
there seems to be negative, self-defeating patterns, the therapist will intervene and
interrupt those to change the course of the conversation during the session. This is done to stop potentially very hurtful
interactions and keeping therapy on track. This is different than the philosophy, oh
yeah, just let them argue so you can assess what's going on. They're generally going to intervene especially
if it's happened more than once. You normally don't need to see a family or
couple argue too much because once you've seen one argument most of the rest are going
to go very similarly. Instead the therapist steps in and coaches
or directs them and uses role modeling to help them learn how to work through this situation
better. They are quick to intervene as the conflict
begins to erupt in the session. Process comments are used a lot, once they've
interrupted the escalation they use process comments. These are comments that draw the family's
attention to immediately what's going on in the room. Right now as you were telling your son how
disappointed you were, or you're not going to let him do it, whatever, you can see your
son immediately -- you can often start with behavioral, he immediately looked down at
the floor. You could see him immediately shut down and
refuse to talk to you as you continue, because he was being quiet and shut down even more,
and after two or three rounds of this, that's when he shot back at you. You interrupt it and help them become more
conscious of what's going on noticing both the verbal and nonverbal interaction patterns. You can say, as all this was going on, little
Suzy over there starting fidgeting and mother looked away. You begin to draw everyone's attention to
what is going on both verbally and non-verbally. These process comments are used to help restructure
and help them become aware of their patterns, and aware of each person's role, and to help
restructure and reshape those interactions so they're more helpful and healthier. Oftentimes when working with conduct disordered
youth, parent skill training is appropriate. They typically focus on three different areas:
setting clear expectations and rules that are developmentally appropriate so they'll
look at the the expectations and rules and make them very concrete and specific, then
having active monitoring and supervision, making sure the parents are taking an active
role in monitoring the behaviors of the children, and having this consistent reinforcement of
the behaviors and having clear behavioral contingencies. Having the parents and teens negotiate reasonable
terms, they work on having them come up with something reasonable. That's more likely to be beneficial and usually
everyone is more likely to adhere to that. Parent skill training, it depends on what's
going on, but it frequently is used especially with this population when they've gotten to
the point where they're being referred by the courts for therapy. Another set of interventions used in functional
family therapy is mutual problem solving. This is a subset of parenting skills. Here you're parenting typically with older
adolescents, they use this mutual problem solving where they identify what the problem
is, identify a desired outcome, agree on how to accomplish the goal, identify the potential
obstacles, and reevaluating the outcomes. Having the teens and parents work together
to come up with realistic goals and ways to achieve it, typically most teens would agree
they would like to graduate past high school classes. They too want to graduate from high school,
it's not just their parents that want them to graduate. You would work with the teens on coming up
with what's a reasonable grade point average to be shooting for, what's a reasonable way
to be achieving that, what's going to happen if you're not meeting the goals, what's the
reasonable course of action there. Oftentimes you can help parents and children
learn how to solve some problems working together. This is using the middle phase to work on
the basic conduct problems presented. This is one that's frequently used later on
in the later phase when you're generalizing these findings, so mutually solving these
problems and other phases in life like peer relationships or school. This is one of the skill sets taught to families,
as needed, when it's appropriate and it frequently is. Another set of interventions that are often
used in functional family when working with children diagnosed with conduct disorder in
their families is conflict management. In this case the therapist is working initially
with the teen and the family to resolve conflict in a healthy way, helping them to learn how
to stay focused on is specific issue, working on having a mindset where they're willing
to work things out, willingness to talk, staying oriented to the present rather than bringing
up every incident from the past. Helping them learn how to have effective disagreements,
effective conflict is very important. Again, this can be generalized to other contexts
in the later phases. Another set of skills that are frequently
addressed in functional family therapy is basic communication, communication skills
for both the teen and family. Focusing on being responsible to others, being
direct, brief communications, not long-winded tirades, being concrete and specific in requests
and complaints, being congruent in how you say things, being an active listener, actually
listening to others. This is a skill set that is frequently taught
in used to work with the families when using functional family therapy. It may not be taught and used with all families
but it's a frequently taught skill set. With all of these interventions there is an
emphasis on matching these, communication skills, conflict management, parenting, all
of those are really matching it to fit the family based on their culture, based on their
current situation, based on their particular problem sequence, the relational function,
the organizational themes that have been discussed. Even though we have these basic principles
all of these are tailored and adjusted to meet the family's unique needs, that's at
the heart of this, it's not a cookie cutter approach as sometimes people think evidence
based treatments are but it's very much modifying all of this to meet the specific needs of
the family. Next we're going to talk about working with
diverse families using functional family therapy. Like other systemic approaches there isn't
an actual theory of health or normalcy. It's not like healthy families look like this,
it's not what is being said here. If you remember the focus is on, what's the
function of the problem symptom, how do we achieve that in a different way? It goes without saying, if you're a functional
family therapist, it needs to be culturally appropriate or using cultural guidelines to
what that might mean. There is this ability to respect for various
forms of family structures that might be relevant to various cultural groups. The goals are very much adapted and based
on the family's cultural norms. It can be used on both collectivists and individualist
value systems. Those sometimes need to be talked about directly
especially when you're working with immigrant families where the teen might align much more
with individualist values and the parent may be aligning with more collectivist values. That would be very much part of the organizational
themes and looking at the function of the symptoms. This approach can certainly be appropriately
used with diverse clients. There are specific studies working with Hispanics
as well as sexual identity. Those are discussed in the text if you want
to go more in depth. As mentioned in the beginning this is an evidence
based treatment meaning it's a manualized treatment that has been used and developed
in clinical trials to work with conduct disorder and "delinquent youth." It is used internationally and really is one
of four widely recognized family treatments for conduct disorder. It has moderately superior outcomes to other
traditional forms of treatment for adolescent youth diagnosed with conduct disorder. They have found that the rates of recidivism
and relapse are correlated very much to the therapist adherence to the model. The more the therapist adheres to the FFT
model, there's a reduced chance of relapse. Again, this is an approach that has a very
strong consistent evidence based for working with conduct disorder and also with substance
abusing youth. I hope you found this lecture helpful and
I encourage you to learn more about functional family therapy.