Functional Family TherapyClinical Training Program

Organizing Themes & ReframingWebinar #4

Thomas L. Sexton, Ph.D., ABPP

Functional Family Therapy Associates

Goals

• Understand how and where to intervene in FFT sessions in all phases

• Role of reframing• Development of organizing themes• Role of your creativity

How do you change the family?

• Client centered attitudes (validation/respect, regard)

• Case Plan– How and who to engage– What skills to add– How to generalize, maintain and support

• Plan for the session– Specific goals – What to ask– Specific phase based techniques

• Finding and using therapeutic “opportunities”

• the “events” clients bring into the room

Problem Behavior

Mom/mother figure

Dad/father figureAdolescent

• Engage them to change• Equip them with skills to solve

the next “problem”-cope/deal with in a new way

• Maintain change over time

Topic of

conversation

Intervention point

Goal of therapy

Engagement/Motivation Sessions

Goals• reduce within family

blame• reduce within family

negativity• build therapeutic alliance

• redefine problem as family focused

• increase hope/expectation for change

Assessment•problem definitions•Problem sequence

•How they “function” or work together

Interventions• reframing

• Develop an organizing theme that is family

focused• diverting and interrupting

• structuring session to discuss relevant topics

Example• Peter is 13 years old. Peter is part Indonesian (his mother was

Indonesian) and Dutch (his father was Dutch). He lives with his mother and his stepfather. He has 2 younger twin brothers, five years younger.

• He lives with his mother and his stepfather. He has 2 younger twin brothers, five years younger.

• According to the referral, the therapist knew that Peter had “fired” three different therapists in the last year. Each time he found them uninteresting, the sessions “boring” and most of the time was spent talking to his mother. The referral gave a characterization of Peter’s mother, Anja, as “motivated to do anything to help.”

• “This might be the last chance Peter has to take advantage of the treatments we are offering. If this referral doesn’t work out, placement should be reassessed as a viable option.”

What to do first

• Involvement in therapy• Incentive to try something new• Family focused “problem definition”• Perceive a “credible” helper

• Begins with how you think about the case (case conceputalization)

Where to begin

• “Problem Definitions” …. Your first opportunity to understand & intervene

• Intervening to build engagement & motivation– Relational Reframing

Relational Reframing

• Intervening to build engagement & motivation– Relational Reframing

Relational Reframing

• When clients negatively/blaming reframe• Over time…reframes become themes• When the themes about each person link

together to provide an alternative explanation of the “problem” it is an organzing theme

Family Therapist

RelationalProcess of Reframing

How:1. Frame-point it out

• Description of:-current behavior

-event taking place

between people/with one personin the session

--reported event/behavioreither between family

or of one person

-exhibited emotion-participation, effort

Acknowledge

Reframe

Impact

2. “BAcknowledge why its important

uild on”/continueBuilding theme that fits

Making the conversation/Session Relevant

-acknowledge what is “wrong”

-do something with “what is wrong” that

makes it motivating/safe

-feel no blame

-talk without negativity

-not alone in problem

RelationalProcess of Reframing

How:1. Frame

2. Acknowledge

1. Meaning-attribution

-event-emotion

(reduces negativity/blame)

2. Challenge themto consider future

possibilities/directions(builds hope that there is

potential, although unknownSolution)

3. Link familymembers together

In struggle/problem(builds family focus/

Interdependence)Listen…listen…listen

Acknowledge

Reframe

Impact

“Build on”/continueBuilding theme that fits

Theme hint(best guess/hypothesis)

Description, statement, question

Suggesting alternative theme

Therapist Family

Thematic explanation of event, problem, family, situation…that is “real“ for both therapist and client

• Themes describe problematic patterns of behavior, and/or relationships, in a way that suggests they may be

motivated by positive (but very misguided) intent(s).

Organizing themes…describe everyone as linked to the pattern that isLinked to the “problem”

• mutually constructed…mutually accepted

Tells “what is the matter”

Content-what is important

What is valued

Listens for….the patternTranslate into a theme (not content)

That links the individual/problem to family

Using REFRAMINGIntroduce “theme hint” into

the conversation

•Occurs within the interaction•Can’t do “reframe outside of the interaction”

Frame/Acknowledgement

Reframe/reattribute

Reframing is built on Themes• Themes describe problematic patterns of behavior, and/or

relationships, in a way that suggests they may be motivated by positive (but very misguided) intent(s).

• Themes provide new “explanations” of problematic and painful patterns that provide– hope for the future and give family members – a reason to “stick with” the difficult change processes which will

ensue – Some sense of their “part” or “challenge”

• Organizing themes….• Link family members together• Explanation of each person, and family struggle

Functional Family Therapy

Reframing is built on Themes• anger implies hurt• anger implies loss• defensive behavior implies emotional links• nagging equals importance• pain interferes with listening• frightened by differences• need to feel OK about self in context of problems• protection• giving up so much power to someone else

• Beginning points to start the reframing process….

Why Reframes & Themes Work

“Respect based” Reframing

• Doesn’t explain away but or “make positive” a bad event

• Reframing finds the strength / nobility in the “bad”/problem/behavior

• which is well intentioned but misguided• while understanding how it is meaningful

for that person

ExampleWhen Peter angrily dismissed Anja, the therapist responded,

“This is exactly the point (acknowledgement-framing)…this is the important issue (framing)…..this is the part that gets lost between you (reframe) when you talk like this.”

Sensing Anja’s stronger emotional reaction, the therapist responded differently. Each time Anja attributed the whole of the family’s difficulties to Peter’s “problem,” the therapist stopped, looked at Anja and said,

“Now I think I understand. This isn’t about you and getting your way, this is about helping him…about you wanting so badly to help (acknowledgement)….it is more about protecting him…(reframe).”

• The themes of loss and protection seemed to link Anja and Peter together and help them overcome the emotional struggle each felt in almost every interaction.

• It really wasn’t that they were “doing” anything different. • These themes seemed to resonate for the therapist and

suggested “hints.” As hints, there were just guesses by the therapist.

• Over time, more and more events seem to fit more elaborated versions of loss and protection. Near the end of the session, the therapist said to Anja:

• Near the end of the session, the therapist said to Anja:

– “I think this sums it up….what you just said, that it was never about controlling him it was only about helping. You know this is important because it is among your most cherished values. Yet, clearly, you quickly find yourself irritated and waiting for Peter to just leave. Yet at the same time you know, somewhere, that Peter is much less disturbed and actually more impendent than it may seem. His anger is often hurt and a feeling of great loss, loss of his mother.… You know that the biggest issue now is not him but finding a way to become more thick skinned and able to look beyond moments of tension without being derailed.”

• Near the end of the session, in response to a strong dismissive reaction by Peter to his mother, the therapist said to Peter:

• “I think I understand …maybe now I am getting a better idea. I must say that I have been sitting here all this time trying to figure out how to respond to this type of response you sometimes make to Anja. At first I thought maybe she was right, that you were just disrespectful, but then I listened more carefully. What I actually hear, although it is done with a tone that makes it difficult to hear the real message…but, I think you mean to protect her and at the same time retain your sense of control over your own life. Unfortunately, it seems that your anger is so quick, that it is easy to miss the lessons she is trying to help you with…it is probably even harder to find her good intent….that seems to be how it works in anger….., do you know what I mean….?”

The Outcome

• Changed relationship• Altered perception of the other• Alliance based therapeutic relationship• Ready for more…”now what do I do…?”

What if…..

• New “events” enter the room• They don’t respond• You notice little change

• No progress toward goals

• How can you adapt?• Reorder importance of the goals?• What do you need to know?• How can you adapt what you know?

Only works when….

– Client centered….model focused– Use events….opportunities

• Opportunities to activate change mechanisms• Accomplish goals by using events

– Take one step at a time• Let the phases build on each other

– When you are active– Guide process…lead the family– Act on your guess– Act before you know– Make hypotheses

Some concluding ideas

• Act before you know• There is no right “reframe” only a good

reframing process• Themes are only as good as they fit• Organizing themes are the foundation of the

rest of FFT• Starting point of behavior change targets• What to help generalize

• Organizing these are “built” not “found” • It takes time…it is a process

• Question and Answer time