James F. Alexander, Holly Barrett Waldron, Michael S. Robbins, and Andrea A. Neeb-Functional Family Therapy For Adolescent Behavior Problems-American Psychological Association (AP

APA Func Family_Title_Activities Teaching Positive Title Page 2/7/13 10:26 PM Page 1
Functional Family
Therapy for Adolescent
Behavior Problems
13190-00_FM_3rdPgs.indd 2
2/8/13 10:52 AM
Functional Family
Behavior Problems
James F. Alexander
Holly Barrett Waldron
Michael S. Robbins
Andrea A. Neeb
American Psychological Association

Washington, DC
Copyright 2013 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication may
be reproduced or distributed in any form or by any means, including, but not limited to, the
process of scanning and digitization, or stored in a database or retrieval system, without the
prior written permission of the publisher.
Published by
750 First Street, NE
Washington, DC 20002
www.apa.org

To order
APA Order Department
P.O. Box 92984
Washington, DC 20090-2984
Tel: (800) 374-2721; Direct: (202) 336-5510
Fax: (202) 336-5502; TDD/TTY: (202) 336-6123
Online: www.apa.org/pubs/books
E-mail: order@apa.org
In the U.K., Europe, Africa, and the Middle East, copies may be ordered from
3 Henrietta Street
Covent Garden, London
WC2E 8LU England
Typeset in Goudy by Circle Graphics, Inc., Columbia, MD
Printer: Edwards Brothers, Inc., Lillington, NC
Cover Designer: Minker Design, Sarasota, FL
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Library of Congress Cataloging-in-Publication Data
Alexander, James F.
Functional family therapy for adolescent behavior problems / authored by James F. Alexander,
Holly Barrett Waldron, Michael S. Robbins, and Andrea A. Neeb.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4338-1294-1 ISBN 1-4338-1294-0 1. Functional Family Therapy
(Program) 2. Family psychotherapy. 3. Behavior therapy for teenagers. I. Title.
RC488.5.A432 2013
616.89'156dc23
2012038947
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
http://dx.doi.org/10.1037/14139-000
2/8/13 10:52 AM
Contents
Introduction................................................................................................... 3
I. Clinical Foundations and Research Support....................................... 15
Chapter 1.
Early Influences: The Cultural, Conceptual,

and Intellectual Zeitgeist of FFT Development............... 17
Chapter 2.
Research on Change Mechanisms................................... 27
Chapter 3.
Research on FFT Outcomes............................................. 37
II. The FFT Clinical Model..................................................................... 63

Chapter 4.
Matching and General Parameters of FFT....................... 65
Chapter 5.
Engagement Phase............................................................ 77
Chapter 6.
Motivation Phase............................................................. 87
Chapter 7.
Relational Assessment Phase......................................... 113
2/8/13 10:52 AM
Chapter 8.
Behavior Change Phase................................................. 129
Chapter 9.
Generalization Phase...................................................... 157
Chapter 10.
Anthony: A Case Example............................................ 167
III. Administering and Extending FFT................................................. 185

Chapter 11.
Features of Successful FFT Implementation.................. 187
Chaper 12.
Training and Supervision............................................... 199
Chapter 13.
Application of FFT to Distinct Populations.................. 219
References.................................................................................................. 233
Index.......................................................................................................... 247
About the Authors.................................................................................... 259
vi contents
2/8/13 10:52 AM
Functional Family
Behavior Problems
13190-01_Intro_3rdPgs.indd 2
2/8/13 10:53 AM
Introduction
Adolescents with behavior problems go by various labels, such as difficultto-treat adolescents, juvenile delinquents, at-risk youth, violent youth, and youthful offenders. They may have disruptive behavior disorder or substance abuse
disorder, and they may be involved with the criminal justice system. These
youth have problematic behaviors, emotions, and ways of thinking that often
affect not only their families, but also their community. These youth, their
families, and their successful treatment represent the focus of this book.
Whatever labels are used to describe them, these adolescents represent
one of the most difficult and recalcitrant treatment populations. Although
family members are often dissatisfied with the youths behavior and intensely
focused on the need for him or her to change, the youth rarely self-refers and
often seems undisturbed by his or her own behaviors. The impetus for treatment often stems from problems that are identified in the youths immediate
social spheres (e.g., family or school) or formal social systems (e.g., juvenile
DOI: 10.1037/14139-001
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett
Waldron, Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
2/8/13 10:53 AM
justice, child welfare). Irrespective of referral source, youth typically are

unmotivated for treatment.
At the same time, parents and other family members seem heavily
invested in viewing problems in the family as resulting from the adolescents
bad behavior. Their ideas of change revolve around a problem individual
focus (the adolescent needs to change) and often have a punitive cast (What
he needs is for someone to smack him over the head and pound some sense into
him!). Therefore, some family members also are unmotivated or unwilling to
be involved in the youths treatment.
Even when therapists can succeed in getting parents and youth into
sessions, additional challenges are invariably encountered. Family interactions are laced with hostility, anger, hopelessness, and frustration, all of which
create a context that runs counter to or precludes adaptive change. It is not
surprising that in many contexts, as many as 50% of youth referred for treatment fail to either show up for a first session or come back for a second session
(Kazdin, Mazurick, & Siegel, 1994). Further complicating the matter is that
parents and parental figures themselves often face considerable challenges,
such as poverty, depression, various forms of posttraumatic stress disorder,
their own residue of previous challenges, substance use, and relational problems (e.g., marital conflict, boyfriends if the mother is single, grandparents
with whom the parents must still live).
Given the multifaceted barriers to adaptive change, treatment is needed
that addresses the entire family system in a holistic way. Successful treatment
programs must take into account more than a simple or individually focused
psychoeducational approach. They must emphasize improving relationshiporiented parenting skills, matching parenting to the developmental capacities
of the youth, and working with parent limitations. Furthermore, treatment
programs must also consider the various ecological systems that impact the
lives of youth and families (Bronfenbrenner, 1979). Youth and families do not
live in a vacuum, and interventions cannot be successful if the complexity
and diversity of the factors impinging on them are not considered.
Over the past 40 years, numerous researchers and clinicians have developed, tested, and refined Functional Family Therapy (FFT)a short-term,
structured, intensive family intervention model for delinquent and substanceusing adolescents. FFT is a strength-based model with a focus on those risk and
protective factors that impact the adolescent and his or her environment. On
average, 12 sessions are conducted over a 3- to 4-month period. These sessions typically occur in clinics and home settings but can also be conducted in
schools, mental health agencies, child welfare agencies, probation and parole
offices, and aftercare systems. Because some families are homeless, the setting
in which FFT can occur is flexible; FFT therapists bring the model to these
challenged families to increase engagement, retention, and positive change.
4 functional family therapy for adolescent behavior problems
2/8/13 10:53 AM
Because families often resist change, FFT first seeks to motivate family members to change and strengthen family interactions. Only after these
initial goals are met does FFT proceed to target the presenting problem (i.e.,
the adolescents problem behavior). Obviously, in most instances, the specific
bottom-line outcomes that are desired by FFT therapists, the parents, and
the referral source (e.g., juvenile justice or mental health system) are heavily
influenced, if not defined, by the nature or source of the referral. Therapists
and treatment systems usually are asked to target such goals as preventing
rearrest, reducing recidivism, preventing self-cutting, getting youth back into
school, preventing out-of-home placement, eliminating drug abuse, and the
like. However, FFT adds a broader view of the change process and clinical
outcomes. In FFT, treatment consists of a series of phases, each involving
a set of intervention processes (assessment and implementation of specific
techniques) and relevant outcomes. The phases are designed not only to
meet immediate, externally imposed outcome criteria but also to help recalibrate family interaction patterns so that more positive family relations will
continue beyond treatment, thus encouraging family members to establish or
reestablish and then maintain new, positive trajectories.
FFT is highly effective. It has been evaluated in more than two dozen
treatment outcome studies focusing on a range of adolescent problem behaviors. The efficacy and effectiveness of FFT have been replicated across sites
and settings (e.g., Barton, Alexander, Waldron, Turner, & Warburton, 1985;
Gordon, Graves, & Arbuthnot, 1995; Waldron & Turner, 2008), across different ethnic and cultural groups (e.g., Alexander, Pugh, & Parsons, 1998;
Flicker, Waldron, Turner, Brody, & Hops, 2008; Waldron, Slesnick, Brody,
Turner, & Peterson, 2001), and across service providers with diverse backgrounds and training (e.g., Barton et al., 1985). FFT is associated with higher
engagement and retention in treatment (e.g., Gordon, Arbuthnot, Gustafson,
& McGreen, 1988; Waldron et al., 2001) and is a well-established treatment
for juvenile delinquent youth and for adolescents with conduct and substance
use disorders (cf. Alexander et al., 1998; Waldron & Turner, 2008). Moreover,
evidence has been found for the preventive effects of FFT for siblings of problem youth and for the long-term effectiveness of the intervention (Klein,
Alexander, & Parsons, 1977). Usually, this prevention effect consists of parents and younger siblings avoiding the behavior patterns of the referred youth.
These results have led the Center for Substance Abuse Prevention and
the Office of Juvenile Justice and Delinquency Prevention to identify FFT as
an exemplary program for both substance abuse and delinquency prevention
(Alverado, Kendall, Beesley, & Lee-Cavaness, 2000). Similarly, the Center
for the Study and Prevention of Violence reviewed more than 1,000 programs
to identify research-based prevention and treatment programs for youth
violence and drug abuse (http://www.colorado.edu/cspv/blueprints/). FFT
introduction
2/8/13 10:53 AM
was designated one of the 11 Blueprints for Violence Prevention programs

(Elliott, 1998). The U.S. Surgeon General also identified FFT as a successful
program for violent, acting-out youth. Such designations reflect the quality and consistency of the evidence supporting the effectiveness of FFT for
troubled youth and families.
In this book, we explain how to provide and administer FFT. We have
written this book with the clinician in mind. We often maintain a quite
personal tone because we want to share and talk with you rather than taking
a more traditional academic tone by talking to you. Often we use examples
of specific youth and families (with disguised identities, of course) so clinicians can experience the clinical reality of these youth and families. We
describe not only the goals of each intervention strategy and technique but
also the specific steps and variations that are involved and necessary for success. At the same time, because FFT also derives strength from our history of
widespread dissemination and training, we also share information relevant
to decision makers, program administrators, clinical supervisors, clinical
researchers, and even legislatures who have the responsibility of how best to
allocate funds to provide the most effective services.
In the remainder of this Introduction, we discuss FFTs conceptualization
of change as a developmental process and outline the five major treatment
phases of FFT. Then we explain the organization of this book.
Change as a Developmental Process
In FFT, we consider change to be a developmental process, with the outcomes from each phase having a cascading effect on processes and outcomes
at subsequent steps. Proximal (i.e., during and between sessions) outcomes
build on one another over time. For example, the degree to which family
members comply with therapeutic directives during the Behavior Change
Phase is related to the extent to which therapists were able to reduce conflict
and build balanced alliances with family members during the Motivation
Phase. Reducing within-family negativity in the first session is an important
outcome in its own right, but the positive effects of such a reduction are fleeting if therapists are not able to create a relational focus and an expectation of
hope in the family at the same time.
FFT therapists are expected to structure their intermediate end-ofsession or treatment-phase goals and their long-term outcome goals. By no
means is this a simple linear progression, but it does represent a coherent
sequence of implementation steps with families. For example, therapists do
not simply jump directly into changing the referral behaviors. They must first
pave the way by engaging family members in treatment and inducing or moti6 functional family therapy for adolescent behavior problems
2/8/13 10:53 AM
vating family members to change by creating a context that is less negative

and even hopeful. They also must assess how the referral problem behaviors
relate to the rest of the familys relationships and needs.
Thus, although FFT is focused ultimately on improving specific problems such as youth violence, delinquency, and drug use, the process of change
itself is dynamic and multifaceted and unfolds throughout treatment. This
dynamic view of outcome recognizes the links between therapist and client
activities at different stages of the treatment process. As noted by Gurman,
Kniskern, and Pinsof (1986), this involves identifying therapist behaviors
associated with the immediate and intermediate outcomes (little os) and
long-term outcomes (big Os) of therapy. Change starts at a micro level in the
familys response to specific interventions, then evolves throughout therapy
and eventually is represented in outcomes observed following the completion
of treatmentand for a long time afterward.
The FFT treatment approach also is organized around the unique construct of relational functions (hence the title Functional Family Therapy).
This construct helps FFT therapists individualize their techniques for each
youth and family to maximize and create protective factors relevant to each
family. Thus, the FFT intervention model provides a structured framework
for treatment while allowing therapists the flexibility of adjusting what they
do and how they do it to the unique aspects of each youth and family. This
dynamic view of the change process thus helps therapists focus on immediate
goals in the session without losing sight of the big picture.
Overview of FFT
The five phases of FFT are depicted graphically in Figure 1: Engagement, Motivation, Relational Assessment, Behavior Change, and Generalization. As the figure shows, the phases are not self-contained. There is
some overlap between phases, particularly between the Motivation Phase
and the Relational Assessment Phase and between the Behavior Change
Phase and the Generalization Phase. For example, at the beginning of the
first session or two, the goals and techniques of the Motivation Phase predominate, while those of the Relational Assessment Phase are less important. Gradually, the emphasis switches to the Relational Assessment Phase
as family motivation increases and less intervention effort is needed to
maintain motivation. The same shift occurs between the Behavior Change
and Generalization Phases.
To prevent dropout and set a positive course of change, FFT front-loads
the intensity of intervention, first in the Engagement Phase and then in the
Motivation Phase, to break up the negative inertia that families have built
introduction
2/8/13 10:53 AM
E
n
g
a
g
e
m
e
n
t
PreTreatment
Behavior
Change
Motivation
Relational
Assessment
Generalization
Session
8+
PostTreatment
Figure 1. Phases of Functional Family Therapy.
up by the time they see an FFT therapist. The degree to which family members
remain in treatment relates to the extent to which therapists are able to
modify negative attributions, reduce conflict, build balanced alliances with
family members early in treatment, and create a framework for families that
spurs their desire for better relationships and better outcomes. This frontloading differentiates FFT from the majority of community-based treatment
approaches, and we believe it is largely responsible for our high retention and
completion rates with families who historically are low in both.
Brief descriptions of each phase follow. Table 1 provides a quick summary of the goals, targeted factors, therapist skills, intervention focus, and
indicators of success for each phase.
Engagement Phase
The goal of the initial Engagement Phase is to enhance family members
perceptions of responsiveness and credibility. As Figure 1 shows, the goals
and techniques of this phase are in effect before the first session begins. From
the first telephone contact with the family, therapists demonstrate a desire to
listen, help, respect, and respond to the family. This phase includes launching therapy in a way that is respectful of any potential issues that may arise in
relation to culture and ethnicity, including factors such as the racial and ethnic sensitivity of therapists and family members and the need for treatment in
the family members language of choice. Thus, from the outset, interventions
are designed to ensure cultural competence and respect.
The main skills required are demonstrating qualities consistent with
positive perceptions of clients, persistence, and cultural and population sensitivity. The therapists focus is on immediate responsiveness and maintenance
of a strength-based relational focus. Therapist activities include ensuring high
2/8/13 10:53 AM
introduction
2/8/13 10:53 AM
Negative perception about or

experiences
with treatment
Reputation of
treatment
agency
Transportation
Therapist
availability
Intake staff skills
and attitudes
High availability
Risk and protective

factors addressed
Therapist skills
Maximize familys
initial expectation of positive
change
Engagement
Goal
Element of
each phase
Intelligence
Perceptiveness
Individual skills
or behaviors
associated
with problem
behaviors
Intrafamilial and
extrafamilial
patterns of
behavior
Family negativity
and blame
Hopelessness
Balanced alliances
Interpersonal
skills (validation,
positive reattribution, reframing, relational
skills)
Identify relational
functions
(connectedness, hierarchy)
in the family
Relational
Assessment
Create a motivational context

for long-term
change
Motivation
Directive, teaching,
structuring skills
Modeling
Setting up, leading,
and reviewing
in-session tasks
Assigning homework
Youth temperament
Parental pathology
Beliefs and values
Developmental level
Parenting skills
Conflict resolution and
negotiation skills
Level of family support
Peer refusal skills
Facilitate individual
and interactive/
relational change
Behavior Change
Intervention phase
TABLE 1
Anatomy of Functional Family Therapy: Phases of Intervention
(continues)
Interpersonal and
structuring skills
Family case
management
Maintain and expand

individual and family
change
Facilitate change in
multiple system
links
Youth bonding to
school
Parent attitudes about
school, peers,
drugs, and so forth
Level of social support
Access and connection
to prosocial youth
and systems
Generalization
2/8/13 10:53 AM
Intervention focus
Element of
each phase
Manage intake
processes to
presenting
agency, self,
and treatment
in a way that
matches to
inferred family
characteristics
Enhance perception of credibility
Engagement
Reduce negativity
and blame
Create hope
Enhance motivation to change
Motivation
Elicit descriptions
of relational
sequences
Relational
Assessment
Facilitate individual
and interactive
or relational change
Behavior Change
Intervention phase
Table 1
Anatomy of Functional Family Therapy: Phases of Intervention (Continued)
Access appropriate
formal and informal community
resources
Anticipate and plan for
future extrafamilial
stresses
Maintain and expand
individual and family
change
Facilitate change in
multiple system
links
Expand domains and
targets for improved
skills within the family and in community
relationships
Reach out to assist in
follow-up and individualized services
Generalization
introduction
11
2/8/13 10:53 AM
Indicators of goal
attainment
Family members
are willing to
engage in at
least one session (i.e., they
show up!)
Blaming attributions decrease;

negativity
decreases;
nonverbal cues
of involvement
increase; and
expressions of
hope, even tentative, increase
Family members
show up for
subsequent
sessions!
Therapist can
identify relational functions
(connectedness
and hierarchy)
in the family
Therapist can
identify and
articulate
predictable
patterns in
problem-related
behaviors and
sequences
Therapist can
conceptualize alternative,
more positive
behaviors that
will serve the
same interpersonal function
Specific changes are

observed in individual behaviors
and interactive patterns (sequences)
that cease the problem behaviors and
develop sustainable
alternatives
New or strengthened
relationships and
communications are
observed with positive peers and community resources
Active participation of
youth is observed in
school or vocational
institutions
availability, telephone outreach, appropriate language and dress, proximal

services and adequate transportation, contact with as many family members
as possible, and a respectful attitude. Engaging family members is a necessary
but not sufficient condition for change in clinically challenging contexts, so
for enduring change, families must then be motivated to change.
Motivation Phase
Motivation is a critical element given that many families do not enter the
treatment process with all members motivated to change. In fact, many enter
treatment motivated to not change; thus, a formal focus on motivation becomes
a crucial element in helping these families. The goals of this phase include creating a positive motivational context, minimizing hopelessness and low selfefficacy, and changing the meaning of family relationships to emphasize possible
hopeful experiences. Required therapist skills consist of relationship and interpersonal skills, a nonjudgmental approach, and acceptance of and sensitivity to
diversity. In this phase, FFT therapists focus on the relationship process; they
work to separate blaming (which emphasizes the person) from responsibility
(which emphasizes the behavior) and to remain strength-based throughout.
Therapist activities in this phase thus include the interruption of highly
negative interaction patterns and blaming through a strength-based relational
focus, pointing process, sequencing, and reframing and themes. A primary
focus is on changing meaning, attributions, and experiences through the use
of what we call change-meaning interventions, such as reframing and themes.
Changing meaning typically involves specific steps of validating the negative
impact of a behavior (e.g., the therapist may say, When your mom saw that
beer bottle in the car, she was hurt and very worried about what you might
have done last night) but then introducing possible benign or noble (but
misguided) motives for behavior (e.g., Maybe leaving the beer bottle where
your mom could see it was your way of telling your mom that you want help).
Finally, the introduction of themes is designed to imply a positive future rather
than the problem-filled past (e.g., Mom, do you have rules about teenagers
driving while drinking beer?). This sort of focus, of course, isnt really about
the single problem event as much as it is about clarifying behavioral and relational expectations by using the problem event to set the stage for future solutions and to change the tone from anger and blame to problem solving.
Relational Assessment
Although the Relational Assessment Phase takes place over the same
general period as the Motivation Phase, we conceptualize the former as a
phase within a phase because it is mostly conducted outside of the therapy
2/8/13 10:53 AM
session using the therapists notes and possibly consultation with other FFT
therapists, whereas the Motivation Phase takes place in the therapy session.
The goals of relational assessment include analyzing information pertaining to individual characteristics and the ways these characteristics impact
relational processes. Specifically, the therapist analyzes whether each family
members statements and behaviors serve to (a) increase connection or contact versus autonomy or distance and (b) establish hierarchy versus influence.
If therapists are to accomplish the goals of this phase, the skills of perceptiveness and an understanding of relational processes and interpersonal
functions are critical. The FFT therapist focuses on intrafamily and extrafamily characteristics and capacities, including family member values, attributions, functions, interaction patterns, sources of resistance, resources, and
limitations. These often are not at all the same for all family members, and, as
such, they create an important agenda for the therapist to address and resolve
in later phases. Therapist activities involve observing and questioning, making inferences regarding the functions of negative behaviors, and switching
from an individual problem focus to a relational perspective.
Behavior Change Phase
Therapist goals during the Behavior Change Phase consist of reducing
or eliminating referral problems through a variety of strategies. Interventions
may include skill building and changing habitual problematic interactions
and other coping patterns at both the individual and the relational levels.
Therapist skills such as structuring, teaching, organizing, and understanding behavioral assessment are required. Therapists often focus on providing
communication training, using technical aids, assigning tasks, and providing training in conflict resolution, negotiation, and problem solving. Phase
activities are focused on modeling and prompting positive behavior, providing directives and information, and developing creative programs to change
behavior, all while remaining sensitive to family members abilities and interpersonal needs. In general, the specific techniques involved in this phase are
based on the extensively developed literatures on behavioral and cognitive
behavioral techniques. However, some of the specific techniques used by various FFT therapists may be more commonly associated with gestalt, narrative
or postmodern, and other client-centered programs. Over the decades, we
have noted that some therapists with quite different backgrounds, such as art
therapy, have been able to incorporate elements of those traditions into the
Behavior Change Phase. Of course, therapists using such seemingly creative
approaches must do so with a clear picture of how such techniques relate
specifically to the unique qualities of each family and how they are in sync
with the familys relational patterns and strengths.
introduction
13
2/8/13 10:53 AM
Generalization Phase
The primary goal of the Generalization Phase is to maintain and expand
individual and family change and facilitate change in multiple system links. In
doing so, the therapist (a) extends the positive changes in individual behaviors and family functioning that were achieved in previous phases into new
situations and contexts, (b) plans for future challenges that increase the risk
for relapse, and (c) incorporates community systems into the change process.
Requisite therapist skills include understanding larger systems, establishing links with diverse community resources, maintaining energy, and
providing outreach. The primary focus is on relationships between family
members and multiple community systems. In addition to extending the positive changes of the Behavior Change Phase, Generalization Phase activities
involve knowing the community, developing and maintaining contacts, initiating clinical linkages to new systems, creating relapse prevention plans,
and helping the family develop independence.
Overview of the Book
As we describe the FFT phases and the techniques and therapist qualities involved in each, our strategy in this book is to move from a broad focus
to a narrow focus, then back again to a broad focus. Thus, the book is divided
into three parts.
We begin this journey in Part I, which explains FFTs diverse theoretical
and clinical roots (Chapter 1), as well as our rigorous research into change
mechanisms (Chapter 2) and outcome effectiveness (Chapter 3). Part II
represents the core of the bookthe FFT model. Chapters in this section
present the FFT model in detail, including general parameters for intervention (Chapter 4), the Engagement Phase (Chapter 5), the Motivation Phase
(Chapter 6), the Relational Assessment Phase (Chapter 7), the Behavior
Change Phase (Chapter 8), and the Generalization Phase (Chapter 9).
Clinical examples are provided throughout Part II, and a special chapter
illustrates all phases of FFT using a single in-depth case study (Chapter 10).
Finally, Part III addresses broader considerations in administering FFT,
including general implementation issues (Chapter 11), training and supervision (Chapter 12), and application of FFT to special treatment populations
such as gang-involved youth or youth in the child welfare system (Chapter 13).
2/8/13 10:53 AM
I
Clinical Foundations
and Research Support
13190-02_P1-Ch01_2ndPgs.indd 15
2/8/13 10:53 AM
13190-02_P1-Ch01_2ndPgs.indd 16
2/8/13 10:53 AM
1
Early Influences: The Cultural,
Conceptual, and Intellectual
Zeitgeist of FFT Development
At the time that Functional Family Therapy (FFT) emerged, few clinical options were available with respect to difficult adolescents and family
dysfunction, regardless of their ethnicity, family structure, and myriad other
dimensions. As a result, it seemed important to learn more about the youth
and familiesthe cultures, populations, and belief systems involvedand
how they might be related to (and reflect) clinical or abnormal levels of
functioning and expression. As a result, choosing a particular clinical approach
simply seemed premature, if not impossible, until considerably more basic
research as well as clinical model development occurred. Thus, we synthesized seemingly different treatment and research literatures to provide more
effective services to children and youth. The development of FFT reflects the
attitude of integrating and synthesizing rather than polarizing. This was an
important aspect of FFT model development, and it continues as a core value
in the model today.
DOI: 10.1037/14139-002
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
17
13190-02_P1-Ch01_2ndPgs.indd 17
2/8/13 10:53 AM
The evolution of FFT can be roughly divided into three periods:

1. Late 1960s to 1970s: Roots of FFT. The cultural and theoretical ideas articulated during this period influenced FFT by
offering diverse theoretical frameworks for clinical problems.
Each of these frameworks had supporters and detractors, but
they created energetic discussion in training institutions,
research contexts, and professional organizations. Within
FFT, these ideas provided support for early clinical and research
investigations.
2. 1980s to 1997: Development of FFT. During these two decades,
the first FFT book was published (Alexander & Parsons, 1982),
national and international interest led to more talented graduate students being involved in FFT research, and more diverse
clinical treatment systems provided opportunities for FFT replication and evaluation in community settings.
3. 1998 to present: Dissemination and expansion of FFT. After the
highly influential publications in the Blueprints for Violence
Prevention series (Elliott, 1998), additional research funding
became available, and opportunities for community-based replications increased dramatically. Larger U.S. state-based systems
and foreign governments solicited training in FFT and ongoing monitoring of implementation. As the dissemination and
expansion of FFT involved greater diversity in populations and
treatment contexts, many community systems invited more
focused FFT interventions involving specific syndromes such
as adolescent substance abuse, acting out of previous trauma
histories, and gang involvement. This expansion also involved
unique treatment contexts such as youth (or sometimes parent)
reentry into the community from residential systems such as
detention, youth homes, and juvenile justice camps.
This chapter focuses primarily on the first two periods. It describes the
theories and cultural movements that helped shape FFT. Indeed, before the
FFT model was developed, its founders reviewed and were trained in diverse
clinical models and literatures. As a result, the theoretical and cultural origins
of FFT are quite diverse, as are the components of FFT. We begin with a discussion of psychodynamic, behavioral, and social learning theories, the predominant influences on psychotherapy from the 1960s and 1970s. Next, we discuss
family systems and communication theories, which contributed a more holistic
approach to treatment. Finally, we discuss additional research that, although
more narrowly focused than the preceding theories, nonetheless had a strong
influence on the FFT model.
13190-02_P1-Ch01_2ndPgs.indd 18
2/8/13 10:53 AM
Psychodynamic, Behavioral,
and Social Learning Theories
The late 1960s and 1970s witnessed the emergence of promising new
theories and avenues for the effective treatment of dysfunctional behavior
problems of children and youth. Until that time, the predominant framework
that the majority of clinicians professed to use was psychoanalysis or one of
its derivatives, and problem behaviors were identified as reflections of individual psychopathology. The early psychodynamic influence on FFT has been
maintained during its four-decade history despite some obvious flaws in the
practice of psychoanalysis with adolescents.
In the psychodynamic framework, at least at the time, both positive
and negative behaviors are seen as expressions of an internal motivational
state. To treat difficult adolescent and family populations, therapists cannot merely engage in what has been identified using such terms as social
engineering without careful attention to the internal dynamics that contribute to behavior. Similarly, the individual, according to FFT, cannot
have complete control of his or her behavior, irrespective of the environment. However, the environment alone cannot determine an individuals
behavior.
Also relevant to FFTs development was the fact that psychotherapy
during the 1960s and early 1970s predominantly involved adult populations.
Treatment outcomes with adolescent populations, especially those with disruptive behavior disorders, were not considered to reflect high effectiveness
or efficacy. Certainly during this time, adolescents seemed to fit the labels of
difficult to treat and treatment resistant. Given the interest in helping adolescent populations and their families, the psychodynamic perspective alone
was not enough, although some of its core was retained.
A strong conceptual shift was offered in the conceptual, clinical, and
research applications of behavioral and social learning strategies and techniques to families. Early pioneers such as B. F. Skinner (1957, 1981) proposed relatively linear causeeffect models, which later visionaries more
formally extended to couples and families (e.g., Patterson, 1982; Stuart,
1971). Albert Bandura (1977) had a strong impact on the treatment community when he proposed a more elaborate cognitive framework that included
a more formal emphasis on reciprocal and bidirectional influences on
behavior both within and between people, in general, and family members,
specifically.
In addition, the shift to behavioral and social learning strategies included
a strong emphasis on empirical demonstrations and replications of core techniques with empirical support and enhanced technical clarity regarding
specific interventions. Although many clinicians were uncomfortable with
early influences
13190-02_P1-Ch01_2ndPgs.indd 19
19
2/8/13 10:53 AM
what they perceived as a technical as opposed to a clinical focus in the behavioral and cognitivebehavioral approaches, the behavioral perspectives insistence on empirical replication and support provided the basis for a strong
shift in the treatment field.
In particular, this strong stance provided a persuasive and easily adopted
foundation for FFT during its formative years. At the same time, we felt it
critical that we not lose the more individual dynamic foundation of the
psychoanalytic perspective. As you will see when we discuss the specifics
of the FFT model, especially relational functions, the contributions of each
individual family members internal representations are coequal to those of
the environment, and each must be incorporated into positive change.
Family Systems and Communication Theories
During the 1970s, family systems and communication theories
(Erickson & Rossi, 1976; Haley, 1976; Minuchin, 1974; Watzlawick, Beavin, &
Jackson, 1967) also were emerging. These perspectives placed less emphasis on internal representations and empirical demonstrations of specific techniques than did psychodynamic and behavioral perspectives, respectively.
Instead, family systems and communication approaches provided more holistic, family-level perspectives that emphasized roles and relationships as a
central, if not causative, aspect of problem behaviors in adolescents.
Probably the most familiar term widely adopted from family systems
therapy was the identified patient, which implied that a referred adolescent
should be considered to reflect a process beyond the adolescent, and it led
to questions about why parents would identify such a role for their son or
daughter. This framework obviously is related to the social learning perspective, which identifies parental influences on adolescent problem behavior,
but it changes the clinical focus to the relational functions of all family members behaviors relevant to an adolescents problem behavior. This emphasis,
adopted as core in FFT, requires that clinicians go beyond referred adolescent behavior patterns to an inclusion of how and why these behaviors are
maintained by not only the adolescents but also the parents in dysfunctional
families.
To relate a simple example, once clinicians adopt the larger systems
perspective, they often notice that an adolescents problem behaviors pull
the parents together (to deal with the kid) to a greater degree than did the
adolescents positive (premorbid in medical terms) behaviors. As a result, the
relational impact of the problem behavior (e.g., adolescent drinking) goes
beyond the youth; it also impacts the parental relationship. This perspective
is elaborated considerably in later chapters.
13190-02_P1-Ch01_2ndPgs.indd 20
2/8/13 10:53 AM
Additional Influences
FFTs formative clinical constructs emerged during the time that psychodynamic, behavioral, and systems perspectives represented strong alternatives
to one another. In fact, early versions of FFT were identified as systems
behavioral (Alexander & Barton, 1980). Very quickly, however, other developing and established conceptual and clinical frameworks, in addition to our
own and others emerging research findings, further influenced the developing
FFT model.
Neuropsychology
The growing literature on biological substrates of adolescent dysfunction ranging from learning disabilities to attention-deficit/hyperactivity disorder (e.g., Sciutto, Nolfi, & Bluhm, 2004; Singh, 2008) provided a reminder
that greater detail at the individual, even endogenous, level could help clinicians better prepare to undertake the more holistic treatment strategy necessary to deal with troubled adolescent populations. This literature reminded us
of the dynamic organization of the adolescent brain. It also helped us broaden
the scope of our focus in terms of trying to understand the ways familial,
social, hormonal, and biochemical forces could impact, for better or worse,
the developing adolescent. Although elaborating the rich information base
provided by this literature is beyond the scope of this book, we wanted to
remind readers of its existence and benefit to us in clinical practice.
Family Interactions With Schizophrenic Youth
In a related vein, during FFTs formative years, we also were informed
by the small but growing literature on family interaction patterns in families
with schizophrenic young adults. The early work of clinical theorists and
researchers such as Jay Haley related specific patterns of family functioning
to schizophrenia. Haley (1963) proposed a novel perspective on relationship
hierarchy in which schizophrenic adolescents and young adults communicated in one-down (e.g., deviant) ways that actually gave them more control
in the relationship with their parents. Complementary (i.e., one-down)
behaviors thereby created a metacomplementary (i.e., one-up) position for
the schizophrenic offspring. Although the specifics of this perspective have
not been retained in FFT, it made us aware that often the superficial aspects of
a behavior may not be the same as that behaviors relational impact. Similarly,
whereas hugging may represent affectionate behavior between a father and
his adult child, giving a hug to a similarly aged female colleague can represent
sexual harassment.
early influences
13190-02_P1-Ch01_2ndPgs.indd 21
21
2/8/13 10:53 AM
Context and relational impact thus often provide considerably more

information than do descriptions of specific behavioral patterns. Although
this concept is not represented directly in the FFT model, Haley (1963) provided a strong family systemic perspective to the traditional views on this
extremely challenging clinical phenomenon. These approaches sometimes
accepted biological substrates as one aspect of the clinical problem, but they
demonstrated that working with these families in the context of the family
created much more positive outcomes.
Leadership
An interesting and unexpected perspective came from business and
social psychology, especially research on leadership models (e.g., Fiedler,
Chemers, & Mahar, 1976). This literature indicated that leadership effectiveness depended on context (leader power, group relationship quality, and
clarity of goals and tasks) rather than some generic quality of a leader and
leadership style. Fiedler and his colleagues demonstrated that groups in the
very most favorable and the very least favorable leadership contexts were better served by a task-oriented (i.e., power-oriented) leader. However, in mixed
contexts (lower but not absent leader power, less positive relationships, and
more ambiguous tasks), a socialrelational leadership style was more effective than a hierarchical, task-oriented leadership style. This latter situation
seemed analogous to the natural developmental trajectories in families with
young adolescents. Specifically, Coles, Alexander, and Schiavo (1974) noted
that as youth move into adolescence, a pattern emerges in which parent
adolescent relationships become somewhat less positive, parental power and
influence decrease (especially compared with the influence of peers), and
the tasks facing adolescents become more ambiguous. Halls (1904) view of
adolescence as a period of storm and stress may not fit universally, but over
a century later, that phrase is still considered appropriate, if not iconic.
Comedians and cartoonists often make a living describing the humorous aspects of this shift to adolescence, but parents, schools, mental health
professionals, and police must deal with the more negative (sometimes even
tragic) implications of this developmental process. Noting this, we were
intrigued but also concerned that although parents of adolescents were normatively going through changing leadership roles vis--vis their children,
none of the available clinical models seemed to help parents adapt leadership
styles to match the context in which they were trying to lead. Instead, during
the 1970s, many parenting programs for dealing with adolescents seemed to
stress a developmental misfit in that parents of troubled adolescents often
were counseled to readopt a hierarchical stance, even though developmentally their children were moving, although ambivalently, toward a more sym22 functional family therapy for adolescent behavior problems
13190-02_P1-Ch01_2ndPgs.indd 22
2/8/13 10:53 AM
metrical position. In addition, it was evident that the parenting tasks during
adolescence (e.g., helping develop gender identity, facilitating good choices
regarding peer groups and educational goals) are much less clear than are the
parenting tasks of childhood (e.g., teaching word recognition, inhibiting selfinjurious behaviors such as sticking forks in electrical outlets). Adolescence is
a time of exploration, ambivalence in various role relationships both within
and outside the family, and often painful social comparison processes involving other youth. Alexander and Parsons (1982) therefore set out to develop
FFT along lines that motivated, taught, and helped parents develop leadership styles that are more relational than hierarchical, thereby being more
developmentally appropriate with teenagers.
Relational Functions
Consistent with FFTs evolving interest in integrating internal and
environmental influences on problem adolescent behavior, anthropologists
(e.g., Watzlawick et al., 1967) and interpersonal theorists (Benjamin, 1993;
Leary, 1957) described the intersection of individual dynamic forces and the
interpersonal context. According to these perspectives, both internal and
interpersonal dynamics come into play when one is trying to understand
human behavior. FFT, as a fundamentally relational model, adopted a version of this both/and perspective with respect to motivation. Consistent
behavior patterns, whether adaptive or maladaptive, are maintained over
time because they function to meet the individual and the contextual or relational needs. As a simplistic example, consider a child who misbehaves to get
attention; the misbehavior functions to elicit attention. The person in the
environment (e.g., the parent) who gives the attention also has a functional
payoff in the temporary cessation of the attention seeking.
This process has been beautifully articulated in the coercion framework of Patterson (1982). As noted earlier, the motivation for the specific
attention-seeking behaviors (mands, according to Skinner, 1957) was seen as
a property of the misbehaving child; the expression of the behavior is heavily
determined by the parent response. If the parent responds with attention to
the childs whining but not to the childs frequent questions, the child will
quickly increase the rate of whining but not of questioning. According to
this perspective, to understand and change the problem behavior pattern (in
this case, whining), the FFT therapist would want to understand the motivation and interpersonal function of this interaction for both participants.
Further, in many situations, intent, as experienced and verbalized by family
members involved in such a pattern, may give little clue as to motivation. For
example, when a parent yells in response to a childs whining, the parent usually intends to stop the childs whining. However, observers of the interaction
early influences
13190-02_P1-Ch01_2ndPgs.indd 23
23
2/8/13 10:53 AM
note what seems to be the opposite effectthat is, the yelling seems to add to
(reinforce) the whining behavior via the attention. Bandura (1986) captured
such processes in the construct of reciprocal determinism. The co-occurrence
of these frameworks with that of the developing FFT model reflected a major
paradigm shift, or at least a new avenue to pursue with challenging clinical
phenomena such as adolescent conduct problems.
As a result, FFT developed a framework to capture the effects or outcomes of problem behaviors as well as the individual factors involved. We
(Alexander & Parsons, 1982, and later Alexander, Waldron, Barton, & Mas,
1989) organized the myriad variables involved into two relational configurations, or domains, similar to and informed by Leary (1957) and later Benjamin
(1993). The first domain represents the degree of interpersonal connection
involved, which ranges from low connection (autonomy) to high connection (considerable interdependency). If constant whining produces constant
attention (e.g., soothing or yelling), FFT posits that the function or purpose
of whining is to achieve greater connection with the parent. If, in contrast,
whining produces consistent parental avoidance or withdrawal, the function
is posited to be lower connection or interpersonal autonomy.
The second relational domain of FFT represents the degree of relational
hierarchy involved, which ranges from one-up, to symmetrical, to one-down.
If a youths pattern of being rude to a parent typically produces an argument
with the parent about whos in charge in this house, FFT posits that the
function of the childs pattern of rudeness is to elicit similar behaviors in
the parent (arguing and being rude in return), creating a more symmetrical
relational configuration. If, however, the parent typically backs down and
gives in to the youth when he or she is rude, such a pattern would reflect
greater relational power on the part of the youth (i.e., one-up in relation to
the parent).
Ecological Theory
Finally, during the evolution of FFT, we were heavily influenced by
Bronfenbrenners (1977, 1986) ecological theory of human development,
which embeds an individuals behavior in the influences of surrounding systems (see also Berk, 2000). This theory provides an overarching framework for
understanding the influence of risk and protective factors at multiple levels of
the adolescent social ecology. Although FFT focuses heavily on the family, it
does not limit the risk and protective factors to the family. Adolescent temperament and neurologically based challenges, parental pathology, permissive parental attitudes toward substance use, lack of youth bonding to school,
association with deviant peers, neighborhood crime, poverty, and unemployment are among the individual family and extrafamily risk factors that have
13190-02_P1-Ch01_2ndPgs.indd 24
2/8/13 10:53 AM
been shown to be related to adolescent substance use and adolescent disruptive behavior disorders up through and including violence and gang involvement. The Behavior Change Phase of FFT targets risk and protective factors
directly. Additionally, the FFT practice of matching (described in Chapter 4)
represents a way to approach the specific families and members with sensitivity
to their particular sets of risk and protective factors.
Conclusion
The diverse theoretical and clinical perspectives of the 1960s and 1970s
often seem contradictory. However, they have been synthesized and made
compatible via the phase-based strategy of FFT (Alexander, Barton, Waldron,
& Mas, 1983). Neither in life nor in specific clinical cases can one pursue
many goals at once, especially if the goals might represent paradigm clashes
and mutual exclusivity. However, by phasing or sequencing treatment goals
and the steps to attain them, therapists can engage in an orderly process to
pursue multiple goals. This must be done in a way that follows a developmental and synergistic trajectory, and, to that end, we adopted a strategy that parallels the development of successful relationships in many forms. In the case
of successful therapeutic journeys, beginning the process successfully involves
different assessments, different clinical techniques, sensitivity to different
qualities of clients, and a different therapeutic focus than do later stages in
the journey. FFTs phase-based model represents and articulates the various
phases and therapeutic tasks necessary for successful outcomes with families
of (often) challenged and challenging youth and family circumstances.
early influences
13190-02_P1-Ch01_2ndPgs.indd 25
25
2/8/13 10:53 AM
13190-02_P1-Ch01_2ndPgs.indd 26
2/8/13 10:53 AM
2
Research on Change
Mechanisms
Our goal in this chapter is to share how researchers have contributed

to answering two critical questions: What do therapists need to do to facilitate positive outcomes? and What are the mechanisms of change? Research
into mechanisms of change, often called process research, has been central in
the evolution of the Functional Family Therapy (FFT) model. In fact, our
research examining the clinical interior of family therapy is an important reason why FFT is recognized as an evidence-based model. Careful research into
the moment-to-moment processes as they occur in FFT can help therapists
understand and apply them successfully across cultures, languages, diverse
family forms, economic levels, and numerous other dimensions that represent
individual differences between all of people. Process research also can help
therapists understand the circumstances under which mechanisms may not
operate in similar ways across various contexts.
DOI: 10.1037/14139-003
27
13190-03_Ch02_2ndPgs.indd 27
2/8/13 10:54 AM
Process research is explicitly concerned with understanding the clinical

interior of treatment, addressing questions about how clients change and what
therapists do to facilitate these changes. In some respects, process research is
intended to open the black box of therapy and provide a rich understanding
of the change process, which is essential for making informed clinical decisions. Process research also helps therapists develop training materials and
approaches that, again, are based on what actually occurs in the treatment
room rather than relying only on case examples and theoretically grounded
assertions. The latter are critical for clinical richness but are not sufficient to
develop a reliable, easily trainable and replicable, and sustainable intervention across diverse contexts.
In this chapter, we review our process research to show the empirical
basis of FFT goals and techniques. We believe that this research provides
therapists with a richer understanding of the underlying mechanisms of
change.
Observational Approach to Research
From the beginning, we have questioned our most cherished assumptions about families, therapy, and the change process. As our primary focus on
families was evolving in early 1970s, our early studies were designed to identify characteristics of families with troubled youth (Alexander, 1973). These
early studies also focused on identifying the effectiveness of specific therapist
characteristics or techniques for client outcomes. It is important to note
that, unlike most studies of that time, which relied heavily on self-reports
from therapists and family members, our research relied on independent
and reliable observations as much as possible. We observed directly how
family members interacted with one another in structured, nontherapy tasks
(e.g.,problem solving, family activity planning) and how they interacted
within the context of therapy. This approach helped us identify clinically
meaningful and relevant family processes by observing directly what families
did when interacting with one another rather than relying solely on what
they said about their family.
Beyond the benefits of the objectivity associated with independent
observations of family functioning, this strategy provided us with a vivid portrayal of interactions in families with a delinquent youth. These observational
studies gave us a window onto behaviors exchanged within families and within
clinical sessions, providing a basis for understanding disrupted family relationships at the same level they can occur in the therapy room. Such research also
helped us formulate specific ideas about better family functioning and effective
therapeutic interactions.
13190-03_Ch02_2ndPgs.indd 28
2/8/13 10:54 AM
Effects of Negativity in Families

One of our earlier studies comparing delinquent and nondelinquent
families suggested a possible mechanism for such high dropout. Specifically,
Barton, Alexander, and Turner (1988) found that families with a delinquent
adolescent expressed higher rates of system-disintegrating communication
(defensive), whereas families with nondelinquent youth expressed more
system-integrating (supportive) communication. That is, delinquent families had higher rates of negativity and blame and lower rates of nurturance,
warmth, empathy, and respect. Moreover, in families with a delinquent adolescent, once defensiveness was present, there was a greater likelihood that
other family members would respond in like manner. This reciprocal responding recurred, resulting in a repetitive sequence of highly aversive interactions
similar to the coercive process described by Patterson (1982).
From a clinical perspective, this pattern of escalation interferes with
effective communication and is associated with a number of problems, including increased risk for treatment dropout and hopelessness. Alexander, Barton,
Schiavo, and Parsons (1976) found that the ratio of negative to supportive
statements was significantly higher in families that dropped out of therapy
than in families that completed treatment. In turn, premature termination
predicted recidivism in adolescents. This research and our early clinical experience highlighted the critical importance of initial family engagement and
the subsequent motivation process with troubled youth and their families.
In many respects, this early research was the precursor for the rich frontloaded interventions that FFT uses to negotiate the early phases of treatment
described in Chapters 5 and 6.
Variables That Affect Family Negativity
Recognizing the link between immediate processes in the room
(e.g.,within-family negativity) and intermediate outcomes such as premature termination and then longer-term treatment outcomes (e.g., rearrest,
recidivism, drug use), we conducted numerous studies to identify how to most
effectively intervene to reduce within-family negativity. Time and again this
research has indicated that family negativity is pervasive among families with
youth who have behavior problems, but it also has shown that systematic
interventions aimed at altering the cognitive and affective context can be
highly influential in reducing this negativity.
In numerous studies, we evaluated how the social context influences family conflict. In the first study, we compared how members of families with a
delinquent adolescent and members of families with a nondelinquent adolescent interacted with one another in different situations (Barton, et al. 1988).
research on change mechanisms
13190-03_Ch02_2ndPgs.indd 29
29
2/8/13 10:54 AM
For example, are interactions different when the situation or context is

viewed as cooperative versus when it is viewed as competitive? The results
of this basic (nontherapy) study demonstrated that even without therapeutic
intervention, it was possible to reduce negativity in families with a delinquent
adolescent by modifying the interaction context (positive/cooperative vs.
negative/competitive). In fact, the families of delinquent and nondelinquent
adolescents showed no differences in their levels of aversive, negative behaviors in the positive interaction context. Although this study did not directly
examine prescribed FFT motivation-enhancing interventions, the results
do suggest that the negative communication processes that pervade families
with a delinquent adolescent are highly malleable and that they are heavily
influenced by the context in which they occur.
Alexander, Waldron, Barton, and Mas (1989) provided families with
different forms of a positive versus negative interactional (attribution)
context by giving them a negative or positive explanation for individuals
behaviors. In the first study, they demonstrated that the families exposed to
a negative attributional context demonstrated more negative behaviors than
did families exposed to the positive context when parents interacted with
each other and with their delinquent adolescent. A second study in this series
demonstrated that the dispositional attributions of parents were influenced
by the manipulation of set, with a dissatisfied set producing negative blaming
attributions and a satisfied set producing nonblaming, positive attributions, a
pattern quite similar to the findings observed in Barton et al. (1988). Finally,
in a third study, they demonstrated that parents negative sets regarding their
adolescents negative behaviors, once established and discussed by the family for 5 minutes, were unresponsive to a subsequent positive reattribution
regarding those behaviors. The latter finding provides important information about the recalcitrance and persistence of negative attributions among
distressed families.
On the basis of such findings, Morris, Alexander, and Turner (1991)
directly examined the impact of positive reframing on the blaming attributions of participants. In this analogue (nonclinical sample of undergraduate
students) study, a blaming attribution was created by exposing participants
to a standard blaming scenario. As expected, this blaming scenario led to an
increase in blaming attributions among participants. The researchers then
introduced participants to one of three different conditions: a positive reframe,
a neutral restatement of the case, or no information at all. Participants who
were provided with the positive reframe showed significantly lower blaming
attributions than did participants in the other two conditions.
Taken together, the data provide support for reattribution techniques
that are explicitly focused on expanding the familys frame to include a more
positive or workable frame in which family members are willing to try out
13190-03_Ch02_2ndPgs.indd 30
2/8/13 10:54 AM
new behaviors. These observational studies have been critical in influencing the development or articulation of specific intervention strategies for
creating a motivational context conducive to adaptive and supportive family
behaviors.
Effects of Specific Therapy Interventions on Family Negativity
The next step in our program of clinical research was to examine the
impact of specific interventions on within-family negativity in therapy sessions. A major focus of this research was to examine how therapists can
operate as agents of change to interrupt negativity and conflict and create a
context that is conducive to change. Specifically, the motivation techniques
described in Chapter 6 are, in large part, derived from research demonstrating that it is possible to change negativity by altering the context in which
family members interact.
Applying the knowledge learned in our prior basic interaction studies
to actual therapy sessions, Robbins, Alexander, Newell, and Turner (1996)
examined the impact of specific types of therapist intervention (e.g., reframing, reflection, structuring) on family members negative attitude during
the initial session of FFT with a delinquent adolescent. This study explicitly focused on identifying effective strategies for altering within-family
negativity, as evident in family members immediate responses to therapist interventions. As in prior research, the results demonstrated the high
rates of negativity that are common among families with delinquent youth.
Moreover, in therapy sessions, adolescents were more likely than mothers to
respond in a negative way following therapists interventions. This is interesting because, quite frequently, adolescents are the target of within-family
negativity, and their behaviors are the focus of change. The results suggested,
however, that their responses varied as a function of specific interventions.
For example, adolescents attitudes were more likely to improve following
therapist reframes compared with alternative intervention strategies such as
reflection and acknowledgment. Thus, we learned that reframing may be used
as a tool for decreasing adolescents negativity in therapy even without other
prior behavioral changes.
Robbins, Alexander, and Turner (2000) further examined the impact
of therapist interventions on family negativity. Similar to the previous study,
the immediate effects of therapist reframing, reflection, and structuring interventions on family member behaviors were compared. However, to control
for the immediate effect of other family members statements, we looked specifically at the following behavioral sequences in families with a delinquent
adolescent: family defensive therapist intervention family behavior
(defensive vs. nondefensive). As in the prior study, the results demonstrated
13190-03_Ch02_2ndPgs.indd 31
31
2/8/13 10:54 AM
that reframing was the most effective strategy for reducing the likelihood
of family negativity. And because these data were gathered in the first FFT
sessions, the results not only replicated the previous finding that adolescents
respond more favorably to reframes than do mothers and fathers but also
provide evidence of the effectiveness of reframing for all family members.
In addition, they demonstrated that such effects could happen very quickly.
Another interesting set of findings that emerged in this research was
that therapist structuring and reflection interventions were no better than
nondefensive family statements in reducing subsequent negativity (e.g., family defensive therapist intervention or family behavior family defensive). Only therapist reframing was associated with a significant reduction in
family negativity.
Effects of Balancing Therapist Support for Parents
With Therapist Support for Adolescents
To further investigate the relationship between in-session therapy processes and outcome, Robbins, Turner, Alexander, and Perez (2003) examined
differences in treatment processes for families retained in treatment versus
those who dropped out of treatment. This work has provided information
about the critical importance of building working alliances with family members and reducing family negativity in preventing dropout. We found that the
balance or similar alignment of therapists with parents and with adolescents
(vs. unbalanced alignment, in which therapists were more closely aligned
with parents than with adolescents or vice versa) was a better predictor of
retention in treatment than the overall level of alliance. In fact, the overall
level of alliance with the therapist was actually misleading, with the highest
levels of alliance observed among parents in the families that dropped out of
treatment. Therapists who were able to achieve a more balanced or similar
level of alliance with parents and adolescents, regardless of whether the alliance was strong or relatively weaker, were more likely to retain the families
in treatment.
These findings are particularly important in guiding FFT therapists in
the first few sessions of therapy, especially with two-parent (or parent figure)
families. It is not uncommon for parents to enter therapy with a strong initial
positive reach out to therapists while the adolescent is quite withholding.
In light of our early session data regarding balance of alliances, however,
it is important for the therapist to avoid going with the flow and responding positively to the parents. This easily can serve to push the adolescent
even further away, consistent with the high dropout rates reported in many
family or individual therapies with adolescents (Kazdin, 1990). A similar
13190-03_Ch02_2ndPgs.indd 32
2/8/13 10:54 AM
situation arises when one parent and the referred youth enter with a strong
alliance with each other whereas another parent is not part of that strong
bond. Further, such a parent (often a stepparent or some form of boyfriend)
often presents as unmotivated to integrate the family. For many of them,
unfortunately, having the adolescent removed or emancipated is their goal
because they never developed much of a positive parentchild bond. Rather
than being unmotivated for a family-integrating intervention, they in fact
enter treatment as antimotivated for such change. It is particularly important for the therapist to create a balance of alliances with all family members
in such difficult and frequently encountered contexts. As a result, therapists
often must work hard to not be especially supportive of one family member or
a dyad if that support is taken by another family member as taking sidesthat
is, facilitating an unbalanced alliance.
How well therapists negotiate early sessions in FFT to build balanced
alliances with family members and manage family negativity is directly associated with dropout. For example, Robbins, Turner, Alexander, Liddle, and
Szapocznik (2012) demonstrated that families that complete treatment have
a significantly higher level of balance in therapist support to family members (support to parents minus support to adolescent) than do families that
drop out. Therapists who worked with families that completed treatment
compared with therapists who worked with families that that dropped out of
treatment engaged in approximately 5 times more supportive interventions
directed to adolescents. Conversely, therapists in the dropout cases appeared
to provide a higher rate of support to parents than did therapists in the families that were successfully retained in treatment; support for parents may
serve to alienate the referred youth, who is frequently the target of parental
negativity. Finally, with respect to family negativity, the results indicated that
family negativity was significantly higher in the dropout families than in the
families that completed treatment.
Taken together, these findings suggest that therapist level of support to
both parents and adolescents is critical and must be approached strategically.
Given that adolescents are frequently the target of much of the negativity
that is expressed in therapy sessions (Robbins et al., 2003), it is not surprising that a systematic attempt to support their perspective is associated with
positive intermediate outcomes such as retention in FFT.
In our most recent process study, Freitag, Alexander, and Turner (2010)
demonstrated that differences in within-family bonding (alliances between
family members), as observed in therapy sessions, were associated with treatment dropout. By the end of the second session, statistically higher rates of
bonding communications occurred between parent and adolescent in families
that completed treatment than in dropout cases. This finding is particularly
salient because it provides empirical support that FFT influences patterns of
13190-03_Ch02_2ndPgs.indd 33
33
2/8/13 10:54 AM
within-family relationships in theoretically predicted ways during the initial

motivation-induction phase of treatment. And it does so quickly! The fact
that independent observers were able to detect differences between the two
outcome groups also has implications for how therapists make decisions in
transitioning from the Motivation Phase to the Behavior Change Phase. For
example, in FFT, the decision to move to behavior change is based on the
therapists assessment that there have been meaningful reductions in family
negativity, an increase in family members expectations or hope, and the
establishment of balanced therapistfamily member alliances. The results of
the Freitag et al. (2010) study provide therapists with an additional withinsession marker (within-family bonding) that helps differentiate successful
and unsuccessful outcomes and that therefore can be useful in case formulation and treatment planning.
Gender in the Context of Family Therapy
For decades, family therapy practitioners and researchers have been
concerned about how family therapy addresses issues of sex-role stereo
typing, the maintenance of traditional gender-based roles, and the distribution of power in family relationships. In developing FFT, we approached
these sensitive issues in the same manner that we approached other aspects
of the treatment processwe tried to replace rhetoric and dogmatism with
conceptually driven data. The results of multiple studies examining the
complex interactions of therapist and client gender and role have been
instrumental in shaping the articulation of FFT principles and in training
male and female therapists who work with youth with behavior problems.
The pattern of results in these studies has been useful for shedding light
about how static characteristics, such as gender, have a profound influence
on clinical processes. This research has helped facilitate in therapists the
notion that all interactions are bidirectional and mutually influential and
are not solely the result of what they do in the session. These interactions
also result from what the therapist represents to the family and its individual members.
In the first study, Warburton, Alexander, and Barton (1980) demonstrated that mothers expressed significantly higher rates of supportive behaviors to female therapists and that this gender-linked pattern was not evident
with fathers and male therapists. However, fathers displayed significantly
higher rates of negative behaviors to female therapists. Female therapists likewise showed elevated rates of negativity to fathers. Further, Mas, Alexander,
and Barton (1985) demonstrated that adolescents spoke less when the therapists were female than when they were male.
13190-03_Ch02_2ndPgs.indd 34
2/8/13 10:54 AM
Subsequent studies also demonstrated that clients appear to prefer that

female therapists behave in ways that are stereotypically feminine. For example, N. Liddle (1989) showed that female therapists use of factual statements
was negatively correlated with positive client attitudes, whereas their use of
warmth and humor was positively associated with client attitudes, particularly
in female clients. Newberry, Alexander, and Turner (1991) also showed that
family members responded differently to male and female therapist behaviors. For example, both mothers and fathers were significantly more likely to
respond supportively to female therapists supportive statements than to male
therapists supportive statements. Also, fathers were more likely to respond
supportively to therapist structuring than were mothers. It is interesting that
the results suggested that female and male therapists also responded differently to client behaviors. Specifically, female therapists were more likely than
male therapists to respond to client supportive statements with structuring
statements.
The results of these studies suggest that female therapists encounter a
very different therapeutic environment than do male therapists, one that is
significantly more negative or even volatile. It should be noted, however, that
we have not observed differences between male and female therapists in their
impact on clinical outcomes (engagement, retention, improvements in family functioning, reduction in adolescent behavior problems). Moreover, in
subsequent process studies, male and female therapists demonstrated similar
rates of implementation of specific intervention strategies (e.g., reframing;
Robbins et al., 2000) and were shown to be similar in their capacity to form
effective working relationships with family members (Robbins et al., 2003).
Our data suggest that although initial impression formation based on therapist gender can powerfully influence the course of treatment, the implementation of family- and respect-based interventions that match family members
interpersonal relatedness needs do not lead to the creation or perpetuation
of a hierarchical authority structure. Instead, they lead to a more egalitarian
process in family communication that is manifested in more equality of talk
time among family members, more family activity, and more positive interruptions (Alexander & Parsons, 1973).
Conclusion
Four decades of clinical experience and research have shaped the evolution of our framework for understanding families and the therapeutic change
process and have served as a critical source of inspiration in our articulation
of FFT as an integrated, phase-based, relational model. The therapists knowledge of core principles, commitment to a relational approach, and belief in
13190-03_Ch02_2ndPgs.indd 35
35
2/8/13 10:54 AM
his or her ability to facilitate positive change are essential ingredients of effective implementation. Ultimately, however, this knowledge, commitment, and
self-efficacy must be translated into interventions in the room with family
members. Theory and principles are relevant insofar as they provide therapists
with a sense of what to do in sessions with families.
Zeroing in on what happens in the room has facilitated our development of the essential elements of FFT. The observational focus of our program
of research has been useful in describing various aspects of the treatment
process, including concrete representations of therapist interventions, family
behaviors, and therapistfamily interactions. Moreover, the results of these
research studies have provided support for implementation of motivationinducing interventions during the initial sessions of treatment. In fact, these
studies have helped identify not just what these interventions look like but
when and how these interventions appear to have a positive effect on family and therapy processes. We have evidence, for example, that behavioral
changes, such as reductions in negativity, increased family bonding, and the
formation of balanced alliances, are particularly positive indicators of treatment outcome when observed by the end of the second session.
The results of process studies have fed directly into our clinical training
and supervision manuals used to train and monitor therapists in controlled
clinical trials and in community-based implementation. Irrespective of the
context of training (research project or real-world implementation), this
research has provided the impetus for the development of complex quality
assurance and monitoring procedures for ensuring that therapists are able to
develop and maintain their competent adherence to FFT.
13190-03_Ch02_2ndPgs.indd 36
2/8/13 10:54 AM
3
Research on FFT Outcomes
Together with clinical observation, basic family interaction research,

and therapy process studies, the efficacy and effectiveness research on
Functional Family Therapy (FFT) shaped the development of the model.
On the basis of a rich tradition of evaluation research spanning four decades,
FFT has become a well-established treatment for a variety of adolescent
behavioral disturbances, including conduct disorder, juvenile delinquency,
and substance abuse. In this chapter, we examine the research findings that
provide the foundation of empirical support for FFT effectiveness and efficacy. Table 3.1, based on Waldron, Robbins, and Alexander (2012), provides
a summary of FFT treatment outcome research.
DOI: 10.1037/14139-004
37
13190-04_Ch03_3rdPgs.indd 37
2/8/13 10:54 AM
13190-04_Ch03_3rdPgs.indd 38
2/8/13 10:54 AM
Delinquent youth arrested

and detained for running
away, being ungovernable, or habitual truancy
N = 40
1316 years old
away, being ungovernable, or habitual truancy
N = 99
1316 years old

away, becoming ungovernable, or truancy
N = 40
Mean age = 15.1 years
Alexander and
Parsons (1973)
Salt Lake City, UT
Alexander and
Barton (1976,
1980); Parsons and
Alexander (1973)
Salt Lake City, UT
Reported sample
characteristics
Alexander (1971)
Salt Lake City, UT
Study and location
Random assignment:
a.FFT, n = 20
b.Client-centered family
therapy, n = 10
c.No treatment control,
n = 10
Random assignment:
a. FFT only, n = 10
b.Individual Therapy (IT)
only, n = 10
c.FFT + IT, n = 10
d.No treatment control,
minimal probation
supervision
Random assignment (ad):
a.FFT, n = 46;
groups, n = 19
c.Psychodynamic family
therapy, n = 11
d.No-treatment control,
n = 10
e.Post hoc selected
controls, n = 46
f.National sample controls,
n = 2,800
Treatment and
comparison conditions
Recidivism: FFT recidivism

was 26%, compared with
50% for no-treatment
controls, 47% for clientcentered family groups,
and 73% for psycho
dynamic family therapy.
Risk/protective process:
FFT produced significant
improvements in family
interactions compared
with all other comparison
conditions.
FFT families displayed
significant changes
in interactions. No
improvements were
found in controls.
618 months
Posttreatment
Family therapy plus
individual therapy
produced significantly
greater improvements in
communication style than
other conditions.
Treatment outcomes
Posttreatment
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT
research on fft outcomes
13190-04_Ch03_3rdPgs.indd 39
39
2/8/13 10:54 AM
Seriously delinquent youth

postincarceration for
severe, chronic offenses
N = 74
Mean age = 20 years
Status offender delinquent

youth at risk for out-ofhome placement
N = 325
Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 2)
Salt Lake City, UT
Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 3)
Salt Lake City, UT
Delinquent youth referred

for 36 status offenses
(e.g., shoplifting,
ungovernable)
N = 27
Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 1)
Salt Lake City, UT
Nonrandom assignment:
a.FFT, n = 30
b.Alternative treatment,
n = 44
a.FFT with trained
therapists, n = 109
b.Community-based social
workers with limited FFT
training, n = 216
a.FFT, n = 27
b.District juvenile justice
base rates
15 months
Posttreatment
13 months
Recidivism: A rate of 26%

was found for the FFT
group, compared with the
51% population base rate.
Significant reductions
were found in family
defensiveness.
Foster placements: A reduction was found in foster
care placement referrals
for the FFT group (11%)
vs. the non-FFT group
(49%).
Treatment services: Units
of service per family were
reduced to less than half
(14.7 vs. 6.2).
was found for the FFT
group, compared with 93%
for those who received
regular services. Those
in the FFT group who did
reoffend did so at a lower
rate or frequency than
those in the regular services group (.202 vs. .474).
(continues)
13190-04_Ch03_3rdPgs.indd 40
2/8/13 10:54 AM
Siblings in 99 families of
delinquent youth (see
Alexander & Parsons,
1973)
N = 99
1316 years old
Drug-abusing adolescents
N = 135
1421 years old
(mean = 17.8)
89% non-Hispanic White,
11% other
Youth reporting regular

substance use
N = 136
Friedman (1989);
Stanton and
Shadish (1997)
Philadelphia, PA
Lewis, Piercy,
Sprenkle, and
Trepper (1990)
Lafayette, IN
Reported sample
characteristics
Klein, Alexander, and

Parsons (1977)
Salt Lake City, UT
Study and location
Posttreatment
15 months
Random assignment:
a.FFT, n = 91
b.Parenting group
intervention, n = 75
Random assignment:
a. Purdue Brief Family
Therapy
b. Family Drug Education
3040 months
Follow-up
period
Random assignment:
a.FFT, n = 46
therapy, n = 19
c.Psychodynamic family
therapy, n = 11
d.No treatment control,
n = 10
Treatment and comparison

conditions
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued )

was found in siblings of
those who had received
FFT, compared with 40%
for no-treatment controls,
59% for client-centered
family treatment, and 63%
for eclecticdynamic
family treatment.
Substance use: Significant
prepost reductions were
found at all follow-up
points, with greater reductions in FFT compared
with the parenting intervention (see Stanton &
Shadish, 1997).
Risk/protective process: FFT
produced greater involvement of parents, lower
family dropout rates, and
improved psychiatric and
family functioning in both
conditions.
Substance use: Reductions
in substance use were
found only for the family
therapy condition involving
an adaptation of FFT, not
for the education group.
Treatment outcomes
13190-04_Ch03_3rdPgs.indd 41
41
2/8/13 10:54 AM
Posttreatment
30 months;
60-month followup of adult
convictions
Random assignment:
a.FFT
b. Group therapy
c.No-treatment control
group, n = 10
Matched assignment, with

more severe cases assigned
to family therapy:
a.FFT, n = 27
b.Probation services as
usual, n = 27
Youth with ADHD diagnosis referred to child

protective services
N = 55
Rural, lower SES delinquent youth; juvenile

offenses: status,
misdemeanor, felony
N = 54
Mean age = 15.4 years
100% non-Hispanic White
Regas and Sprenkle

(1982)
Lafayette, IN
Gordon (1995,
Study 1); Gordon,
Arbuthnot,
Gustafson, and
McGreen (1988);
Gordon, Graves,
and Arbuthnot
(1995); Gustafson,
Gordon, and
Arbuthnot (1985)
Southeastern Ohio
ADHD: FFT and group therapy produced significant

improvements in ADHD
behaviors at home and at
school, but only FFT also
led to significantly more
positive perceptions of
the family.
Recidivism: The FFT group
had an 11% recidivism
rate, compared with 67%
in the regular services
group, at 30-month followup and a 8.7% recidivism
in the regular services
group, at 60-month
follow-up.
Cost analyses: Costbenefit
analysis on these groups
indicated that FFT had
significantly lower direct
costs than treatment as
usual.
(continues)
13190-04_Ch03_3rdPgs.indd 42
2/8/13 10:54 AM
Reported sample
characteristics
Chronic offenders, average of 34 prior institutional commitments
N = 49
1718 years old
Delinquent youth released

from incarceration
N = 52
1617 years old
Delinquent adolescents
N = 46
Study and location
Gordon (1995,
Study 2); Gordon
and Arbuthnot
(1990)
Southeastern Ohio
Gordon (1995,
Study 3)
Ohio
Lantz (1982)
Salt Lake City, UT
Random assignment:
a.FFT, n = 22
b.Alternative treatment,
n = 24
Matched assignment:
a.FFT, n = 27
b.Probation services as
usual, n = 25
a.FFT, n = 49
b.Statistical control:
empirically derived risk
of recidivating based
on age, age of onset,
number of offenses
Treatment and
Posttreatment
16 months
1218 months
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued)

had a 30% rate of a new
conviction after treatment, compared with
the 60%75% average
expected for the statistical
control group, and a 12%
rate of new institutional
commitment, compared
with a 50%60% average
expected for statistical
controls.
showed a 33% recidivism
in the services as usual
group
Recidivism: Rates of 50% in
the FFT group and 88%
in the control group were
found.
Foster placement: 18%
of the FFT group were
placed outside the home,
compared with 72% of the
control group.
Treatment outcomes
13190-04_Ch03_3rdPgs.indd 43
43
2/8/13 10:54 AM
Youth referred following arrest for serious

offenses
N = 89
Community-based sample
of multiproblem delinquent youth and their
families
N = 62
Hansson, Cederblad,
and Hk (2000)
Lund, Sweden
Hansson, Johansson,
Drott-Engln, and
Benderix (2004)
Lund, Sweden
Matched assignment:
a.FFT, n = 45
b.Social work services as
usual, n = 50
Random assignment:
a.FFT, n = 40
b. Treatment as usual, n = 49
18 months
24 months

in the treatment as usual
group were found.
Externalizing: The FFT
group was associated
with greater reductions in
youth and parent reports
of youth externalizing.
in the services as usual
group were found.
Youth symptoms:
The FFT group was associated with greater reductions in youth and parent
reports of externalizing
and internalizing
symptoms.
Risk/protective
process: Improved family
functioning and reduced
maternal depression,
somatization, and anxiety
were found in the FFT
group.
(continues)
13190-04_Ch03_3rdPgs.indd 44
2/8/13 10:54 AM
French, Zavala et al.

(2008); Waldron,
Ozechowski, Brody,
and Turner (2012);
Waldron, Slesnick,
Brody, Turner, and
Peterson (2001)
Albuquerque, NM
Study and location

Substance-abusing youth,
moderate to heavy use
N = 120
1318 years old
(mean = 15.6)
47% Hispanic, 8%
Native American, 7%
other
Reported sample
characteristics
Random assignment:
a.FFT
b. Individual CBT (ICBT)
c. Group CBT (GT)
d. Integrated FFT + CBT
Treatment and comparison

conditions
19 months
Follow-up
period
TABLE 3.1
Substance use: The FFT,

GT, and FFT + CBT
groups all showed significant reductions in substance use from pre- to
posttreatment or followup; FFT and FFT + CBT
were superior to ICBT.
Improvements in family
functioning associated
with substance use reductions were found in the
FFT conditions but not
in GT, supporting family
improvement as a mechanism of change in FFT.
Cost analyses: FFT and
FFT + CBT were more
cost-effective than ICBT
or GT at posttreatment
because of lack of posttreatment effects for these
conditions. GT was more
cost-effective than the
other treatment conditions
at follow-up, albeit with
delayed benefits.
Treatment outcomes
13190-04_Ch03_3rdPgs.indd 45
45
2/8/13 10:54 AM
Delinquent youth
N = 750
Youth with substance use

disorders, moderate to
heavy use
N = 88
1319 years old
(mean = 15.7)
50% Anglo, 50% Hispanic
Aos, Lieb, Mayfield,

Miller, and
Pennucci (2004);
Aos, Phipps,
Barnoski, and
Lieb (2001);
Barnoski (2002)
Washington State
Flicker, Waldron,
Turner, Brody, and
Hops (2008)
Albuquerque, NM
12 months
Posttreatment
Assignment (nonrandom)
based on caseload capacity:
a.FFT, n = 427
b. Wait-list controls, n = 323
Random assignment:
a.FFT
b. Integrated FFT + CBT
Recidivism: Youth with competent and adherent FFT

therapists had significantly
lower recidivism (34%)
and felony recidivism
(13%) compared with
controls (43% and 19%,
respectively).
Cost analyses: Financial
benefits of the dissemination were estimated at
$7.50 for each dollar of
program cost for adherent
therapists.
prepost reductions in
substance use were
found for all youth in FFT
and FFT + CBT. Hispanic
youth with Hispanic
therapists showed greater
decreases in substance
use compared with Hispanic youth with Anglo
therapists. Ethnic match
was not related to treatment outcome for Anglo
youth.
(continues)
13190-04_Ch03_3rdPgs.indd 46
2/8/13 10:54 AM
Sexton and Turner

(2010)
Washington State
Slesnick and
Prestopnik (2009)
Albuquerque, NM
Study and location

Alcohol-abusing runaway
youth
N = 119
1217 years old
(mean = 15.1)
29% Anglo, 44% Hispanic,
11% Native American,
5% African American,
11% other
Youth referred to
community agencies
Reported sample
characteristics
Random assignment:
a.FFT
b.Probation services
as usual
Random assignment:
a.Home-based ecological
family therapy, n = 37
b. Office-based FFT, n = 40
c. Services as usual, n = 42
Treatment and
12 months
15 months
Follow-up
period
TABLE 3.1
Recidivism: Overall, no
differences were found
between FFT and services as usual. However,
when therapist adherence
to the model was high,
FFT showed significantly
greater reductions in
felonies (35%) and violent crimes (30%), with
a marginally significant
reduction in misdemeanors (21%), compared with
services as usual.

pre- to posttreatment
reductions in alcohol and
drug use were found for
all three conditions.
Treatment outcomes
13190-04_Ch03_3rdPgs.indd 47
47
2/8/13 10:54 AM
Hops et al. (2011);

Waldron, Hops,
et al. (2012)
Albuquerque, NM,
and Salem/
Portland, OR
Waldron, Brody,
Turner, and
Ozechowski (2012)
Albuquerque, NM
Youth with problem drinking or other substance

use disorders, moderate
to heavy use
N = 140
1319 years old
(mean = 16.3)
44% Hispanic, 7%
Native American, 4%
other
heavy use
N = 245
1319 years old
(mean = 15.8)
49% Anglo (non-Hispanic
White), 51% Hispanic
19 months
19 months
Random assignment:
a.FFT
b. Individual CBT (ICBT)
c. Group CBT (GT)
d. Integrated FFT + CBT
Random assignment of Hispanic and Anglo youth to

treatment conditions:
a. Individual CBT (ICBT)
b. Integrated FFT + CBT

reductions in substance
use were found for youth
in both treatment conditions, with greater reductions in marijuana use for
Hispanics in FFT + CBT
compared with ICBT.
HIV-risk behavior: Significant pre- to posttreatment
reductions in HIV-risk
behaviors were found for
high-risk youth in both
treatment conditions, with
greater reductions in ICBT
than in FFT + CBT and
greater reductions for high
risk Anglos, compared
with high-risk Hispanics.
(continues)
Substance use: All four conditions showed significant

reductions in alcohol use,
and youth in the FFT,
ICBT, and GT (but not
FFT + CBT) conditions
showed significant reductions in marijuana and
other illicit drug use from
pre- to posttreatment.
13190-04_Ch03_3rdPgs.indd 48
2/8/13 10:54 AM
Waldron,
Ozechowski,
Brody, Turner,
Hops, and Scherer
(2012)
Albuquerque, NM
Study and location
Treatment and
Random assignment to postFFT aftercare condition:
a.FFT + home aftercare
(FFTHA)
b.FFT + group CBT
aftercare (FFTG)
c.FFT + telephone
aftercare (FFTTA)
Reported sample
characteristics
heavy use
N = 74
1318 years old
(mean = 16.4)
54% Hispanic, 6% other
12 months
Follow-up
period
TABLE 3.1
Substance use: The FFT

group showed significant
reductions in substance
use, with changes maintained in FFTHA and
FFTTA but not FFTG.
FFTHA was superior to
FFTG at 12 months.
Delinquency: The FFT group
showed significant reductions in delinquency, with
reductions maintained in
FFTHA and FFTTA but
not FFTG. FFTHA and
FFTTA were superior to
FFTG at 12 months.
Improvements in depression, anxiety, withdrawn
behavior, and family functioning were found for all
FFT conditions.
Treatment outcomes
13190-04_Ch03_3rdPgs.indd 49
49
2/8/13 10:54 AM
Substance use disordered

youth, moderate to
heavy use
N = 140
1319 years old (mean =
16.5)
41% Hispanic, 19%
other
Youth referred to community agencies for behavioral disturbances at risk

for or diagnosed with
substance use disorder
Projected N = 288
1317 years old
Waldron, Brody,
Turner,
Ozechowski, and
Hops (2008)
Albuquerque, NM
Robbins et al. (2011)

Los Angeles, CA
16 months
611 months
Random assignment to treatment sequence:

a.group CBT, then FFT if
needed (GTFFT)
b.group CBT, then individual CBT if needed
(GTICBT)
Random assignment to
supervision:
a.FFT, supervision as usual
+ observation-based
feedback to therapists
b.FFT, supervision as usual
(no observation-based
feedback)
19 months
Random assignment to treatment sequence:

a.FFT, followed by group
CBT (FFTGT)
b.Group CBT, followed by
FFT (GTFFT)
c. Integrated FFT + GT
Substance use: Preliminary

findings showed significant reductions in substance use from pre- to
posttreatment and followup for treatment completers in all conditions,
with superior retention
and greater improvements in depression and
substance use across all
youth in the integrated
FFT + GT condition.
Substance use: Preliminary
findings showed significant reductions in substance use from pre- to
posttreatment and followup for treatment completers in both conditions,
with superior retention
and greater improvements
in substance use across
all youth in the GTFFT
condition.
Study is in progress.
Note.ADHD = attention-deficit/hyperactivity disorder; CBT = cognitive behavior therapy; FFT = Functional Family Therapy; GT = group therapy; SES = socioeconomic status. Data
from Waldron, Robbins, and Alexander (2012).
Dually diagnosed
depressed and
substance-abusing
youth, moderate to
heavy use
N = 170
1319 years old (mean
=16.4)
32% Hispanic, 4%
African American, 10%
other
Rohde, Waldron,
Turner, Brody, and
Jorgensen (2012)
Albuquerque, NM
Portland, OR
FFT as an Evidence-Based Treatment

The increased emphasis in community treatment settings on evidencebased treatments (EBTs) in recent years is based on the assumption that clients
and families receive better care from clinicians who implement empirically
supported treatments (Sackett, Richardson, Rosenberg, & Haynes, 2000;
Woody, Weisz, & McLean, 2005). However, the clinical science through
which EBTs are defined has advanced over time, and, consequently, the standards for evaluating the quality of treatment outcome research have evolved,
lending greater confidence to study findings.
Criteria that can help guide potential consumers of EBTs in determining the adequacy of the evidence have been set forth by scholars in the field
(cf. Chambless et al., 1996; Nathan & Gorman, 2002). These criteria serve
to strengthen the conclusion that a treatment works and ensure that positive
findings for a treatment are due to the treatment itself rather than to other
factors that could influence the outcomes. Examples of these criteria include
the following:
77
77
77
77
77
77
77
77
77
77
at least two rigorous controlled trials that compare outcomes

for a given treatment to a no-treatment, placebo, or alternative intervention condition, including study replication by an
independent team of investigators;
treatments received by clients determined by random assignment;
research staff who are unaware of the treatment assignments;
fully described samples, with inclusion and exclusion criteria,
so that it is clear to whom the findings may apply;
appropriate outcome measures;
large enough samples to have adequate statistical power for data
analysis;
manuals used to guide treatment and to help ensure that the
treatment can be replicated as tested;
measures of therapist adherence to the treatment models;
adequate length of time for follow-up assessments; and
clearly described statistical methods.
According to Chambless et al. (1996), treatments are considered well

established if positive outcomes, relative to comparison interventions, have
been demonstrated in at least two clinical trials conducted by independent
investigators. Interventions are considered probably efficacious if they meet
the same standards of a well-established treatment but the outcome studies
have all been conducted by a single investigator or team of researchers. As
the number of investigations increases and the pattern of empirical support
13190-04_Ch03_3rdPgs.indd 50
2/8/13 10:54 AM
across studies remains consistently positive, one can have greater confidence
in the models effectiveness.
Treatment outcome findings obtained through randomized clinical
trials and other research provide the basis for establishing FFT as an EBT.
Although some of the early FFT studies were limited by small sample sizes or
nonrandom assignment to treatment, these studies represented the standard
for outcome research at that time and provided a foundation for increasingly sophisticated clinical trials of FFT. FFT has now been evaluated by a
number of independent investigative teams using more rigorous design and
methodological standards that have affirmed the promise of the early studies.
Moreover, when all of the research evidence is considered as a whole, the
consistent pattern of positive findings for FFT that has emerged across investigators, populations, and settings establishes a formidable cumulative record
of empirical support for FFT.
Early FFT Outcome Studies
The first controlled trial of FFT was conducted with 40 delinquent
adolescents between the ages of 13 and 16 years who had been arrested and
detained for truancy, ungovernable behavior, or running away from home
(Alexander, 1971). Youth were randomly assigned to one of four comparison
conditions: FFT, individual therapy (IT), FFT plus IT, or minimal contact
with probation staff. FFT and FFT plus IT were associated with significantly
greater improvements in family functioning than the other two conditions at
a 10-week follow-up assessment. A second FFT evaluation of youth similar
to those in the prior study (Alexander & Parsons, 1973) compared outcomes
for youth and families who received FFT with outcomes for youth who participated in community-based treatment programs involving either a clientcentered family therapy condition or an eclectic psychodynamic family
therapy condition and outcomes for youth in a no-treatment control condition. Recidivism rates, examined at baseline and at a measurement point
occurring between 6 and 18 months after program completion, were significantly lower for the FFT group than for the other intervention conditions
(p .025), with recidivism rates as follows: 26% for the FFT group, 50% for
the no-treatment group, 47% for the client-centered family therapy group,
and 73% for the psychodynamic family therapy group. FFT was also associated
with significantly greater improvements in family functioning compared with
the other three conditions. It is interesting that neither of the ongoing treatment programs, although widely used in the community, was more effective
than no treatment, and the eclectic psychodynamic family therapy condition
13190-04_Ch03_3rdPgs.indd 51
51
2/8/13 10:54 AM
produced negative (i.e., iatrogenic) effects. Because both studies involved random assignment to treatments and focused on key outcomes (i.e., family functioning, recidivism), the importance of these studies in forming the empirical
foundation for FFT has endured over time.
Subsequent research built on the early studies, evaluating FFT across new
settings and populations of clients and therapists. For example, in a 3-year
follow-up investigation of families participating in the study, Klein, Alexander,
and Parsons (1977) evaluated the impact of FFT on recidivism and sibling
delinquency. The findings revealed the primary prevention benefits of FFT. FFT
was associated with significantly lower recidivism rates for siblings (p .005)
relative to the other conditions. The rates of legal involvement of siblings were
20% for those involved in FFT, 40% for no-treatment controls, 59% percent
for the client-centered family therapy group, and 63% for the eclectic psychodynamic family therapy group. In a series of three studies, Barton, Alexander,
Waldron, Turner, and Warburton (1985) replicated the FFT findings with less
formally trained clinicians, with a seriously disturbed delinquent population,
and within a cost-effectiveness context comparing FFT with out-of-home
placement for youth referred for treatment through the family court (dependency) as opposed to the juvenile justice (delinquency) system. Although each
of the replications had methodological limitations relative to current research
standards, taken together they provided support for the generalizability of FFT
across client populations, therapists, and measures.
Given the span of years, contexts, and investigators represented in the
outcomes reported above, it is important to note that the core phase-based
FFT model has remained constant. What has changed, in a programmatic and
evolving way, is the detail used to describe the phases, techniques, and intervention strategies. Initial research undertaken during the first decade of FFT
focused on basic components of the model (see Chapter 4, this volume) and
simple demonstrations of positive outcomes and were done in house (i.e., in the
clinic within which the model was developed and tested initially). Because of
this, we shared a common language and way of thinking, which were described
in the first formal articulation of the model (Alexander & Parsons, 1982).
However, as others outside of our system expressed interest in our early positive
outcomes, we were obligated to articulate more fully the philosophical bases for
the model as well as the specifics of implementation. The designation of FFT
as a Blueprints for Violence Prevention model program (Elliott, 1997, 1998)
necessitated, by specific request, that we further and more completely elucidate
the model, especially the phases and techniques involved.
To use one example, the construct of reframing was used in the 1973
(Alexander & Parsons, 1973; Parsons & Alexander, 1973) and 1976
(Alexander, Barton, Schiavo, & Parsons, 1976) research publications but was
not well developed or articulated until the 1982 book (Alexander & Parsons,
13190-04_Ch03_3rdPgs.indd 52
2/8/13 10:54 AM
1982). The descriptions of reframing found in the current volume (see

Chapter 6), in contrast, are much more extensive and elaborated in examples
(both in shorter vignettes and more extensively in Chapter 10) because the
wide diversity of therapists undertaking the model often represent different
cultures, disciplines, and treatment contexts. Thus, to enhance the successful
adoption and use of FFT across this diversity, we felt it necessary to use more
complete articulations and ways of expressing the constructs based on our
direct experience of training others in FFT in diverse contexts.
FFT Evaluations by Independent Investigators
Independent replications of FFT effectiveness studies have been
undertaken by a number of investigators. Several such studies were conducted by Donald Gordon and his colleagues with juvenile offenders in
Southeastern Ohio. One study involved 54 culturally and economically disadvantaged juvenile offenders with two or more offenses (e.g., misdemeanor,
felony) and their families living in the rural Appalachian region of Ohio
(Gordon, Arbuthnot, Gustafson, & McGreen, 1988). Half of the sample
received home-based FFT delivered by relatively inexperienced graduate
student therapists, and half, comprising youth entering the juvenile justice
system during the same period the other youth were referred to FFT, received
standard probation services. The court records were evaluated, on average,
28 months after court referral. The recidivism rate associated with FFT was
11% compared with 67% for the probation-only group, indicating significantly better outcomes for FFT (p .005). A costbenefit analysis indicated
that the direct costs from out-of-home placements and cost of treatment
for the two groups were higher for the probation-only group (Gustafson,
Gordon, & Arbuthnot, 1985). The significantly lower direct costs for the
FFT group are consistent with other reports (Kinney, Madsen, Fleming, &
Haapala, 1977) and do not take into consideration further potential cost
savings as youth move into adulthood.
In a 3-year follow-up study of the families in the original study, Gordon,
Graves, and Arbuthnot (1995) again found significantly better outcomes for
FFT relative to the probation-only condition (p .01), with 41% of youth in
the probation-only condition reoffending but only 9% of youth reoffending
in the FFT condition. Although the study did not involve random assignment, which would have served to equalize the likelihood of recidivating
between the two groups, the study may have involved a more stringent test
of FFT than random assignment would have provided because the court systematically referred the more severe youth offenders to FFT and the milder,
first-time offenders to the probation supervision condition.
13190-04_Ch03_3rdPgs.indd 53
53
2/8/13 10:54 AM
Another study evaluated FFT combined with intensive probation supervision for serious multiple offenders released from state institutions (Gordon
& Arbuthnot, 1990). A 21-month follow-up revealed a 30% recidivism rate.
A statistical comparison of youth matched on number of prior offenses and
age at first offense would have yielded an expected recidivism rate of 60% to
75%, providing further independent evidence for the effectiveness of FFT for
delinquent youth.
Independent replications of FFT effectiveness have also been conducted
in Sweden by Kjell Hansson and his colleagues. In one of the first randomized
studies on juvenile delinquency in Sweden, Hansson, Cederblad, and Hk
(2000) examined the efficacy of FFT compared with treatment as usual with a
sample of 89 delinquent youth and their families. Results indicated that FFT
was significantly more effective than treatment as usual in reducing behavior
problems both at 1- and 2-year follow-up, according to official registers. FFT
was also shown to have a positive influence on the psychiatric health of both
the young people and their mothers. The authors concluded that FFT seems
to be an effective method for treating early juvenile delinquency by diminishing the relapse rate by 50%. Hansson, Johansson, Drott-Engln, and Benderix
(2004) replicated these findings in a community-based setting. In this replication, FFT was delivered within a framework of cooperation between social
welfare, child psychiatry, and a drug treatment unit. Compared with treatment as usual, the FFT condition showed improved family functioning and
fewer psychiatric symptoms (both internalizing and externalizing) after treatment. Both parents and youth showed higher optimism and valued the treatment highly. The pattern of results in this community-based replication was
similar to that of the earlier university-based research with the same method.
The impact of FFT with drug-using adolescents and their families has
been extensively tested in several clinical trials and a meta-analysis. Friedman
(1989) conducted a randomized clinical trial comparing FFT with a parenting skills group intervention for 135 families of youth between the ages of
14 and 21 years with heavy alcohol and drug use (e.g., daily cannabis use).
For families who received treatment, results for both the FFT and parenting
groups showed significant reductions in substance use of more than 50% at
follow-up, with improvements in other areas of functioning as well. However,
the rates of engagement in treatment differed dramatically, with 93% engagement in FFT versus 67% in the parenting condition. In a reanalysis of the
entire intent-to-treat sample in which families who terminated treatment
prematurely were included as treatment failures, Stanton and Shadish (1997)
found significantly greater substance use reductions for the FFT than for the
comparison condition.
Later evaluations of FFT for adolescent substance use disorders were
conducted by Holly Waldron and her colleagues in New Mexico and Oregon.
13190-04_Ch03_3rdPgs.indd 54
2/8/13 10:54 AM
In a series of three randomized trials, this investigative team examined the

efficacy of FFT relative to other active treatment conditions such as group
and individual cognitive behavior therapy (CBT). The team has also examined FFT in the context of aftercare interventions designed to sustain FFTs
positive effects beyond treatment. In all of the studies, youth were referred
for substance abuse treatment and presented with a variety of co-occurring
problems including juvenile delinquency, depression, conduct problems,
attention-deficit/hyperactivity disorder, anxiety, risky sexual behaviors, and
school failure. The studies were designed to meet the highest standards for
clinical trials, including random assignment; assessment staff naive to treatment condition; manual-guided treatments; careful measurement of outcomes, mediators, and treatment adherence; 12 to 19 months of follow-up
assessment; and the use of advanced data analytic procedures.
In the first trial, 120 adolescents were randomly assigned to one of four
intervention conditions: FFT, individual CBT, FFT offered in combination
with individual CBT (FFT + CBT), or a group skills-based intervention
(Waldron, Slesnick, Brody, Turner, & Peterson, 2001). Adolescents were
offered 12 hours of FFT, CBT, or group or 24 hours of therapy in the combined
condition. Substance use, determined via self-report and urine toxicology
screening, was measured at baseline and 4, 7, and 19 months following treatment initiation. Adolescents in the FFT condition showed significantly lower
marijuana use following treatment compared with the CBT or group condition and were more efficacious, and FFT was more cost-effective than the
other two conditions at posttreatment (French et al., 2008; Waldron et al.,
2001). The posttreatment effect size for FFT was 0.79, compared with 0.43 for
FFT + CBT, 0.29 for group, and 0.00 for CBT. No overall drug use reductions
were found for CBT, although significant reductions were found for the group
condition at the 7-month and 19-month assessments, indicating a delayed
positive treatment response. No differences were found between FFT and
group or CBT at the later follow-up points, and the findings suggested that
the positive effects of FFT dissipated to an extent over time.
The second trial extended the work of Waldron et al. (2001) by testing
the efficacy of FFT, individual and group CBT, and an integrated intervention involving eight to nine FFT and five to six CBT sessions for adolescent
alcohol abuse and dependence (cf. Waldron & Turner, 2008). The study
included 146 drinking teens, many with co-occurring marijuana and other
illicit drug use. All four conditions were associated with significant reductions in substance use (p .001) from baseline to each of the three follow-up
assessments and in binge drinking (p .03 at 5- and 8-month follow-ups;
p .001 at 19-month follow-up) across the 19-month follow-up period. The
effect sizes for pre- to posttreatment change were as follows: d = 0.79 for
FFT, d = 0.61 for individual CBT, d = 0.25 for group CBT, and d = 0.33 for
13190-04_Ch03_3rdPgs.indd 55
55
2/8/13 10:54 AM
FFT + CBT. The findings indicate that there are multiple pathways to change
in adolescent substance use and provide further empirical support for FFT
for this population. The relatively poorer findings for the integrated FFT +
CBT intervention may have been due to an inadequate dose of FFT or to
negative or deleterious effects in combining these two theoretically disparate
approaches. Overall variability in treatment responding, including significant posttreatment relapse, was also observed for a number of youth, pointing
to the need for continuing care for youth to maintain their treatment gains.
The third trial, a two-site study conducted in New Mexico and Oregon,
evaluated the two 14-session interventions examined in the previous study,
individual CBT or integrated FFT + CBT, for 245 adolescents and their families (cf. Hops et al., 2011; Waldron & Turner, 2008). Both treatments showed
significant reductions in marijuana use through the 18-month follow-up,
with Hispanic youth responding significantly better to FFT + CBT than to
CBT. Anglo youth improved equally well in both interventions throughout
the follow-up period. These findings are consistent with the earlier trials and
demonstrated that Hispanic substance-abusing adolescents and their families have as good or better outcomes with interventions involving FFT than
Anglos do.
In a more fine-grained examination of ethnicity outcomes, Flicker
et al. (2008) identified 43 families from the earlier trials who had an ethnically matched FFT therapist (14 Hispanic and 29 Anglo families and therapists) and 45 nonmatched families (i.e., 30 Hispanic families with Anglo
therapists and 15 Anglo families with Hispanic therapists). Although both
Hispanic and Anglo youth achieved significant drug use reductions, ethnically matched Hispanic adolescents demonstrated greater decreases in their
substance use relative to Hispanic adolescents with Anglo therapists. Ethnic
match was unrelated to treatment outcome for Anglo youth. Compared with
Anglo therapists, Hispanic therapists may be more attuned to core cultural
values in Hispanic families and may be more able to tailor the way they interact
with Hispanic adolescents and parents in accordance with such values. Taken
together, the findings suggest that FFT is a particularly good fit for Hispanic
youth and families, especially when delivered by a therapist similar in ethnic
background.
The clinical trials examining FFT for substance-abusing youth were
included in a recent meta-analytic study (Waldron & Turner, 2008). In this
meta-analysis, 46 different treatment conditions that included 2,307 adolescents treated for substance abuse disorders were examined. The combined
sample evaluated several therapy models, including FFT and other empirically oriented family therapy approaches, group CBT, individual CBT, and
a minimal treatment condition. The effect size associated with reductions
in drug use was significantly larger for the family therapy condition relative
13190-04_Ch03_3rdPgs.indd 56
2/8/13 10:54 AM
to the minimal treatment condition (p .007). No differences were found

between the minimal treatment condition and the integrated family therapy
plus CBT conditions, in which families received a smaller dose of family
therapy. Thus, the strongest support for family therapy for the three clinical
trials included in the meta-analysis was for the higher dose of family therapy.
Empirical evidence supporting FFT for adolescent substance use disorders was also found in a study investigating FFT and aftercare interventions
(Waldron, Ozechowski, Brody, Turner, Hops, & Scherer, 2012). The primary
purpose of the study was to examine whether the beneficial effects of FFT
can be made more durable by the addition of a transitional follow-up care
component. In an effort to bolster the positive effects of FFT and enhance
long-term treatment effects on adolescent drug use, researchers randomly
assigned adolescents and their families to receive one of three aftercare
interventions following a standard 14-session course of FFT: a home-based
intervention to further enhance family relationships and refine family skills in
the natural environment, a clinic-based group CBT intervention, and a
telephone-based weekly conference call between the family and the FFT
therapist. Consistent with the prior clinical trials, FFT was associated with
a 24.6% pre- to posttreatment reduction in marijuana use. This reduction
was maintained and additional posttreatment improvements were achieved
during the 12-month follow-up period for the home-based and telecounseling interventions, whereas relapse occurred in the group-based aftercare
intervention.
Slesnick and Prestopnik (2009) compared a home-based ecologically
based family therapy (EBFT) approach to office-based FFT and services
as usual (SAU) for runaway youth with problem alcohol use. Adolescents
were recruited for participation in the study through homeless shelters after
running away from home. Both EBFT and FFT were associated with significant reductions in alcohol and other drug use. The FFT group showed
significantly greater reductions in alcohol use (p .01) and drug use disorder diagnoses (p .05) compared with the SAU group. However, more
families in the home-based EBFT condition engaged in treatment relative
to the office-based FFT condition, and they completed significantly more
sessions than did those in FFT, with averages of 10.31 and 6.51 sessions,
respectively. Because both EBFT and FFT are multisystemic family-based
treatments and there was a Treatment Condition Setting confound in the
design of the study, it is unclear whether the better engagement and session
completion for EBFT were due to something unique about the intervention
or simply to the impact of meeting with families of runaway youth in their
homes. Nevertheless, the marked impact of both EBFT and FFT on reducing alcohol and drug use relative to SAU provides additional evidence in
support of FFT.
13190-04_Ch03_3rdPgs.indd 57
57
2/8/13 10:54 AM
Community-Based Effectiveness Research

The findings of the FFT evaluations described above show clear evidence
for the positive effects of FFT for a range of adolescent problem behaviors
when implemented with the scientific rigor provided by randomized clinical
trials and other treatment outcome studies involving intensive supervision
of therapists. Empirical support for the effectiveness of FFT as implemented
in real-world community treatment settings by practicing professionals with
diverse training backgrounds is also essential because efforts to transport efficacious interventions into practice settings have often met with limited success due to the complex nature of the settings, constrained resources, and
limited influence of investigators over organizational and other factors that
may affect adoption and implementation (Fixsen, Naoom, Blase, Friedman,
& Wallace, 2005). One measure of FFTs successful transport into community
practice is the models adoption or reach (Glasgow, Lichtenstein, & Marcus,
2003). Currently, the dissemination organization for FFT (FFT LLC) has
trained nearly 300 local, state, national, and international organizations,
with more than 1,100 FFT therapists trained and more than 12,000 families
around the globe served annually. Large-scale multisite implementations are
ongoing in California, Washington, Pennsylvania, New York, Florida, and
the Netherlands.
One of these sites, the Washington State Institute for Public Policy,
conducted a formal evaluation of FFT for juvenile offenders who had been
remanded for probation services. Approximately 600 rural and urban youth
in 14 Washington counties were randomly assigned to receive either FFT or
probation services as usual (Aos, Phipps, Barnoski, & Lieb, 2001; Barnoski,
2002). The 40 participating FFT therapists all had at least 90 days of FFT
experience under the supervision of the FFT LLC program. The study
revealed that only half of the therapists adhered competently to the FFT
model and that model adherence was linked to outcome such that significant
reductions in recidivism were achieved only by therapists who implemented
FFT with fidelity. When cases for adherent therapists were combined with
those for nonadherent therapists, no differences were found between FFT
and probation services as usual. These results were obtained even though the
adherent therapists tended to be assigned more severe cases. Barnoski (2002)
estimated that competent delivery of FFT could reduce recidivism rates for
felonies and violent crime by as much as 35%. Cost analyses indicated that
for competent FFT therapists, the estimated financial benefits of the dissemination were $7.50 for each dollar of program cost (Aos, Lieb, Mayfield,
Miller, & Pennucci, 2004).
Expanding Barnoskis (2002) sample to 917 families, Sexton and Turner
(2010) reexamined FFT effectiveness for juvenile offenders in Washington
13190-04_Ch03_3rdPgs.indd 58
2/8/13 10:54 AM
State. They also provided a more detailed description of the adherence rating
procedures (see also Sexton, Alexander, & Mease, 2004, for a description of
the protocol). In both the Barnoski (2002) sample and the expanded Sexton
and Turner (2010) sample, adherence ratings were completed for a portion
of participating families and sessions. Therapists each presented one active
case per week in supervision meetings and, on the basis of these presentations, clinical supervisors later completed ratings of low to high FFT model
adherence on a 6-point Likert-type scale. The rating system was designed to
measure the knowledge of core FFT principles therapists reflected in their
presentations, their understanding of the family within the FFT framework,
and their compliance with the manual-specified goals for each phase of the
clinical intervention (Sexton et al., 2004). As in Barnoskis preliminary
study, positive outcomes were found only for competently adherent therapists. However, Sexton and Turner noted several methodological weaknesses
in the study. Ratings were dependent on the supervisors clinical judgments of
therapist adherence to the FFT model, which were sometimes reconstructed
from memory long after therapist case presentations (Barnoski, 2002).
Moreover, therapist representations of their in-session behavior could have
seemed adherent to supervisors even if therapists were not actually engaging
appropriately in the behaviors they described.
Clearly, measuring FFT adherence is critical for ensuring that FFT is
implemented in community settings with integrity. The link between therapist adherence and outcome is well-known. One of the single most significant challenges associated with implementing EBTs in community practice
is establishing therapists competent adherence to a treatment model and
sustaining fidelity (Forgatch, Patterson, & DeGarmo, 2005; Henggeler,
Clingempeel, Brondino, & Pickrel, 2002; Hogue et al., 2008; Mihalic &
Irwin, 2003; Rogers, 2003). To address the key issue of enhancing treatment
competence, FFT LLC recently developed and implemented a sophisticated
Web-based application designed to monitor highly structured FFT therapist
progress notes and supervisor and client ratings of therapist competence. The
process helps maximize sustainability for community programs by limiting
costs. Hence, the supervision process involves feedback to therapists based
on the progress notes and therapistsupervisor discussions of therapist performance. The current supervision and adherence monitoring system, changed
as a result of the problems detected in the Barnoski (2002) and Sexton
and Turner (2010) studies, is designed to enhance therapist adherence and
improve overall treatment effectiveness.
The effectiveness of this new adherence monitoring system is currently
being evaluated in a randomized clinical trial of FFT effectiveness being
conducted by the authors of this volume in a collaborative effort involving
Oregon Research Institute, FFT LLC, and the California Institute of Mental
13190-04_Ch03_3rdPgs.indd 59
59
2/8/13 10:54 AM
Health. The study will examine the impact of two distinct supervision strategies on therapist competent adherence and clinical outcomes: the supervision
approach currently used by FFT LLC and an observation-based supervision
approach in which therapists sessions are recorded and reviewed weekly by
supervisors. The study has significant implications for establishing parameters
to achieve positive outcomes in practice settings in that observation-based
supervision may lead to greater therapist adherence that is linked to better
outcomes, but the approach is also associated with higher costs that may not
yield greater cost-effectiveness. More important, the study reflects our ongoing commitment to FFT evaluation research and the desire to attain optimal
care for families.
Adaptations of FFT
A number of investigations have examined FFT in an adapted form
or examined the therapeutic conditions that influence FFT efficacy and
effectiveness (Lewis, Piercy, Sprenkle, & Trepper, 1990; Sexton & Turner,
2010; Waldron et al., 2001). Any implementation of an intervention that
deviates meaningfully from the model followed in each of the clinical trials
used to establish that intervention as an EBT is considered an adaptation.
Recognizing adaptations of FFT as distinct from the original model (e.g.,
Alexander & Parsons, 1982; Alexander, Pugh, & Parsons, 1998; Barton &
Alexander, 1981) is important because the research evidence supporting the
original model cannot be presumed to extend to the adapted or revised version.
There is general consensus among treatment researchers and scholars (e.g.,
Bellg et al., 2004; Blakely et al., 1987; Byrnes, Miller, Aalborg, Plasencia, &
Keagy, 2010; McHugh, Murray, & Barlow, 2009; Mihalic & Irwin, 2003) that
interventions are effective only when they are implemented with high levels
of fidelity and that, when elements of an EBT are modified, the research evidence supporting an intervention cannot be extended to the adapted model.
Moreover, disseminating and implementing an adaptation of an EBT as
if it derived from the same empirical evidence as the original model could
easily backfire and undermine public confidence in scientific claims that we
have programs that work (Elliott & Mihalic, 2004, p. 52). Thus, we are cautious in discussing adaptations to the model and emphasize that adaptations
require their own systematic research to establish independent empirical
support. Yet adaptations can be an extremely valuable source of information regarding how FFT may be tailored to unique populations or settings to
achieve enhanced outcomes. We consider here some FFT adaptations that
have been evaluated, the evidence there is to support them, and what we
might learn from them.
13190-04_Ch03_3rdPgs.indd 60
2/8/13 10:54 AM
Lewis et al. (1990) developed an intervention integrating FFT strategies and structuralstrategic therapy and evaluated the intervention
relative to a parenting skills intervention with 136 substance-abusing
youth. The integrated family therapy and parenting skills intervention
both showed significant reductions in drug use, with a greater percentage
of youth in family therapy decreasing their use. Because Lewis et al. did
not include an FFT-only intervention, the differential effectiveness of the
adapted intervention relative to FFT is unknown.
In the clinical trials conducted by Waldron and her colleagues (reviewed
in Waldron & Turner, 2008), the integration of FFT with individual CBT
sessions for drug-abusing youth was compared with FFT as a standalone treatment. Taken together, the findings from these studies provide some empirical support for the integrated intervention. However, compared with FFT as
a standalone treatment, the overall effects appeared weaker for the adapted
version of FFT, suggesting that not all attempts to integrate FFT with other
intervention approaches are successful.
These findings are consistent with preliminary findings from a study
involving 180 youth with co-occurring substance use disorders and depression (Rohde, Waldron, Turner, Brody, & Jorgensen, 2012). Adolescents
referred for substance abuse treatment and receiving diagnoses of comorbid
depression were randomly assigned to one of three treatments involving a
group CBT intervention for depression and FFT for substance abuse. All
adolescents received 12 sessions of group CBT and 12 sessions of FFT, with
group CBT followed by FFT in one treatment condition, FFT followed by
group CBT in the second condition, and an integrated combination of
FFT sessions and group CBT sessions in the third condition. From baseline to the first follow-up, the study revealed large effect sizes (p < .01) for
reductions in depression for all three treatment sequences among dually
diagnosed youth with more severe depression (average d = 1.45), with no
significant differences between conditions. Among less severely depressed
youth, moderate but significant (p < .05) effect sizes for change were found
(average d = 0.53) for reductions in depressive symptoms, also with no differences by sequence condition. With respect to substance use, FFT showed
a greater reduction than did CBT or integrated treatment (d = 1.41 for FFT
vs. d = 0.56 and 0.48 for CBT and integrated treatment, respectively) at
the first follow-up. For the more severely depressed youth, offering CBT
first followed by FFT was associated with greater substance use reductions.
Taken together, the findings support the efficacy of FFT in reducing both
depression and substance use for youth with co-occuring depressive and
substance use disorders, with some evidence that offering CBT before FFT
may produce better outcomes for the most severely depressed youth who
have dual diagnoses.
13190-04_Ch03_3rdPgs.indd 61
61
2/8/13 10:54 AM
Another adaptation of FFT is described in the book Functional Family

Therapy in Clinical Practice: An Evidence-Based Treatment Model for Working
With Troubled Adolescents (Sexton, 2010). The version of FFT described by
Sexton deviates from the original clinical model described by Alexander
and colleagues (cf. Alexander & Parsons, 1982; Alexander et al., 1998) in
several meaningful ways. Examples of potentially significant differences that
appear in Sextons version but not in the original, tested model include the
concept of organizing themes, the assessment of the presenting problem, the
notion of accepting personal responsibility, and the blurring of engagement
and motivation techniques. For example, Sextons articulation of organizing
themes shares some similarities with the descriptions of relational reframes
and themes in the tested FFT model.
However, Sextons (2010) global focus of organizing themes (they
weave the individual views together into an explanation of the problem that
involves everyone in the origin of the difficulty; p. 98) represents a much
more complex strategy compared with the tested models more straightforward
and specific articulations of change-focus (interrupting, diverting, pointing
process) and change-meaning (relabels, reframes, themes) techniques. The
addition of organizing themes involves having therapists develop comprehensive themes, gain acceptance in the family for the new omnibus theme,
and link these themes to behavior change and generalization. The increased
complexity of this addition to the model could make therapist adherence to
the model more difficult to achieve, consistent with findings from Sexton and
Turner (2010). The modifications related to assessing the presenting problem
and accepting personal responsibility are markedly different from the nonjudgmental, relational emphasis of the FFT model as it has been implemented
over the past three decades. Research evaluating the effectiveness of this
adapted model is needed to establish the approach as evidence based.
Conclusion
Therapists understanding of the research evidence is important because
it can strengthen therapist convictions about the model, thereby helping
them implement the model with greater confidence.
13190-04_Ch03_3rdPgs.indd 62
2/8/13 10:54 AM
II
The FFT Clinical Model
13190-05_P2-Ch04_2ndPgs.indd 63
2/8/13 11:04 AM
13190-05_P2-Ch04_2ndPgs.indd 64
2/8/13 11:04 AM
4
Matching and General
Parameters of FFT
The scope and diversity of specific behavioral and larger-system (ecological) targets of Functional Family Therapy (FFT) change are well articulated in the extensive literature on high-risk youth, especially those with
externalizing disorders. The extensiveness of such targets, however, can quickly
overwhelm policymakers, program developers, and therapists. Years ago,
Hawkins, Catalano, and Miller (1992), for example, identified numerous risk
and protective factors that cut across multiple levels (biological, behavioral,
cognitive) and domains (individual, familial, extrafamilial). The list has not
become shorter over time!
Determining which of these factors to address in any given intervention
or how to aggregate resources and programs to address them all is daunting,
to say the least. Sadly, early research with adolescents with disruptive behavior
problems demonstrated that the overall success in treating these youth was
disappointing. During the past two decades, however, several effective programs
DOI: 10.1037/14139-005
65
13190-05_P2-Ch04_2ndPgs.indd 65
2/8/13 11:04 AM
have emerged for working with troubled youth. Not surprisingly, these programs
are based on comprehensive, systemic theories that provide a framework for
organizing and understanding the interrelationships among multiple risk and
protective factors across clinical domains. As shown in the overview table in
the Introduction, FFT targets common risk and protective factors in each phase
of treatment. Additionally, FFTs technique of matching is used in every
phase of treatment to relate effectively to each unique family. In this chapter,
we discuss both matching and the general parameters of FFT.
Matching
A critical strategy that FFT therapists use to approach each family (and
individual family member) on the basis of their particular sets of risk and protective factors is called matching. Matching in FFT means attempting to create
an interpersonal relationship in which family members are in sync with the
therapist and are consequently able to move through subsequent steps in
the process with the fewest impediments. Matching is related to but not the
same as the construct of mirroring, which also is widely used in the treatment
field. Matching, like mirroring, requires attention to the clientsin the case
of FFT, to the youth, to the parent system, and to the ways they are embedded
in the community. However, the meaning of matching in FFT often is quite
different from that of mirroring.
As noted by Haley (1963), in cases in which one person is behaving in a
hierarchically one-up or one-down way, the relationship can be stable, positive,
and adaptive when another person behaves in a complementary waythat
is, in a manner that matches or is congruent with the behavior. To use but
one example, the parentchild relationship normally proceeds well when the
parent is comfortable and competent in one-up parenting (teaching, setting
limits, supporting from a position of knowledge and experience). If the child
matches with one-down behaviors (seeking knowledge, accepting information,
following limits), interactions are smooth and positive. If, in contrast, the child
challenges the one-up position of the parent by refusing to comply and instead
attempts to set his or her own rules, struggles ensue. The so-called terrible 2s
seem to represent such a process, and this phase is developmentally quite
common. The issue is not that such challenges occur; for us, the issue centers
on how they are resolved, both in childhood and throughout development.
Clinical Examples of Matching
In FFT, the therapist reflects (but in a positive way) the same inter
personal distance or reaching out embedded in the others communication.
13190-05_P2-Ch04_2ndPgs.indd 66
2/8/13 11:04 AM
If a parent reaches out warmly to the therapist, a matching therapist response

would be reflected in a warm response. However, if a family member initially
comes across as cold and distant, the therapist would respond with more interpersonally distant behaviors: less smiling, more formal speech, fewer emotionally charged words. Although we recognize that this latter example may,
on the surface, fly in the face of much psychotherapy tradition, it avoids
crashing through defenses or communicating in ways the family member has
yet to let the therapist know are comfortable for him or her. To use more colloquial language, good FFT therapists are not simply ubiquitous warm fuzzies.
Instead, they know when and how to behave with emotional distance, embracing warmth, overt control, and unassertive acceptance, depending, of course,
on what the circumstances and family member presentations call for. FFT and
FFT therapists are contingent and flexible, depending on what the model and
research identify as the best strategies to produce positive proximal, as well as
long-term, outcomes for the families.
As an example, an older White male therapist may have difficulty credibly mirroring the dress and behavior of a tattooed young Latin male youth.
However, this therapist can attempt to match in terms of the core relational
processes of respect (in this example, respeto) and by keeping his language in
similar cognitive, behavioral, and emotional domains as the youth. However,
the principle of matching can challenge even the most experienced therapist. Consider the severely depressed youth who is hierarchically one-down
(e.g., whiny rather than assertive) and relationally distant with the therapist
when FFT begins. The therapist would not want to mirror (i.e., mimic) selfdemeaning talk and depressed facial expressions. Rather, the therapist would
choose to speak more slowly rather than quickly, have a look of concern rather
than being enthusiastic and upbeat, and express more caution rather than
optimism regarding the future. Such matching, of course, will be necessary
only during the very early sessions because FFT, as we describe in great detail
throughout the book, is heavily front-loaded.
Also, in such a situation, the therapist would respond to others in the
room, such as a single mother, in a similar matching way. If the parent is
immediately assertive in blaming and urging the youth to speak up, the therapist
might respond as follows:
I can hear how hard you are trying to move things along, Mom, and
I want to thank you for that; often, many parents dont seem to even care
enough to try so hard. Or they have given up. It looks like you havent
and I can count on your energy to help us move along. However, Janice
seems to be saying, by being so quiet, that she needs things to slow down.
In fact, you both are pretty good at being clear about what you seem to
want, but right now they dont appear to be the same thing. And it makes
sense that Janice is not as clear about expressing what she wants, maybe
matching and general parameters of fft
13190-05_P2-Ch04_2ndPgs.indd 67
67
2/8/13 11:04 AM
because she doesnt want to make us uncomfortable, or maybe because

she isnt real clear in her own mind right now. As you know, that is not
uncommon in 15-year-olds. So Im probably going to talk louder and
faster with you, but when Janice and I talk, I will slow it down and be
softer. And by the way, I started to call you Mom, but I didnt clear
that with you first. Do you want to be called Mom, Gloria, Ms. X, or...?
This example is dense with what might be called techniques (which

are discussed at length in Chapters 59). We begin very actively, rather than
simply by asking lots of questions or allowing blame or sullenness to linger.
We also work very hard, at the outset, to give families the idea that we are
looking for understanding and solutions rather than adopting a stance of
telling them what is wrong with them or proposing solutions without first
getting to know them and developing trust and mutual respect.
Along the same lines, it would not be uncommon for an FFT therapist,
facing a menacing youth in a first session, to remark,
If you would excuse me [showing respect] while I talk to your mother a
minute...[to the mother] Ive been told by some other young men your
sons age that its important to maintain a tough image. I certainly had to,
growing up in New York. [Note that this comment represents matching in
a way that might be possible despite big differences in age and ethnicity.]
So I want to respect that, just as I want to respect what you [the mother]
must do to survive with all the stresses you face.
As we discuss later, this strength-based characterization of the mother highlights

that she does, in fact, survive, but saying it this way also acknowledges her
stresses. Such comments reach out to both the referred adolescent and the
mother yet challenge neither. They attempt to send a very clear message that
I am here to hear and respect you on your terms first and foremost.
Importance of Matching to the Diversity of Normal Families
Normal, or nondelinquent, families reflect huge diversity in terms of
leadership styles and hierarchy. They include different levels and kinds of
parentchild attachment, they include children with different temperaments
who are treated differently by parents, and they include normal rather than
ideal parents. In light of this, FFT has adopted a strong stand: Effective treatment requires that our interventions match the realities of being normal,
with all the diversity that comes with such families, rather than adopting a
uniform one-size-fits-all approach that seemed to dominate the treatment
field at the time FFT was evolving.
In one example of using research to provide a basis for matching families,
Malouf and Alexander (1974) produced data that seemed to dispute certain
13190-05_P2-Ch04_2ndPgs.indd 68
2/8/13 11:04 AM
culturally held beliefs about single mothers. Single mothers undoubtedly face
serious challenges, yet our research demonstrated that single mothers could
parent as effectively as married mothers do. To do so, however, they needed to
adopt different parenting styles as necessitated by their context-specific parenting role relationships. Yet although the parenting context of single mothers
clearly is different from the parenting context of married mothers, most
parenting manuals and treatments available in the 1970s simply instructed
mothers with regard to parenting techniques with little (if any) attention paid
to the parenting context or family structure! Also, in perusing the self-help
books of the time, we noted that the focus rarely included the unique challenges
of single versus married mothers. Instead, the single parent literature seemed
primarily to lament such situations as broken homes and fatherless boys.
Facing this, we sought to develop an alternative using adaptive and effective
single parents as our models for change.
To create a strategy for dealing with such challenges and goals, as well
as the changing demographics of many referred families, FFT thus became a
context-driven and family-specific intervention rather than a unitary or
standard protocol approach applied uniformly to all families. To be successful in
such a contingent approach, we recognized the need to be familiar with and
help different families develop a large number of different parenting techniques and strategies that are individualized for the many configurations of
parents and youth we see. These configurations include single mothers, single
fathers, married or cohabitating different-gender adults, same-gender parents
or parent figures, and a grandparent still raising a child who has a child of her
own. Adding diversity based on culture and ethnicity, socioeconomic status,
and health challenges to the mix makes it clear that intervention must be
matched to the unique circumstances of each family struggling with adolescent problems.
Structured Parameters
The phase-based nature of FFT also implies a generic structure regarding the parameters of treatment. By parameters, we mean how FFT is linked
to other systems, who participates in treatment, where sessions are located,
what the average number of sessions is in the typical course of treatment, and
how booster sessions are used. In the remainder of this chapter, although we
discuss these general parameters, it should be noted that these parameters are
not fixed, rigid expectations. FFT is intended to be applied in a contingent and
responsive way with each family. Therefore, the clinical process and general
parameters unfold in a unique way for each family. These parameters are
intended to provide merely a rough estimate of the typical or average course
13190-05_P2-Ch04_2ndPgs.indd 69
69
2/8/13 11:04 AM
of treatment. This information is useful for program planning as well as for

reviewing individual therapist (or team) performance and for developing
quality assurance plans.
Linking With Systems Before, During, and After Treatment
Figure 4.1 portrays our overall framework for considering how the
FFT direct treatment phases link with the diverse community systems that
surround us. The presence and influence of those systems remind us that
productive referral channels, as well as positive links with systems that impact
families post-FFT, must be understood, respected, and maintained.
We all are aware that families do not live in a vacuum, and our treatment approaches cannot be successful if we treat families as if they do. Further,
because we work with such challenged youth and families, we, as FFT therapists,
rarely have the opportunity to work with self-referrals or families not already
involved with other systems. As a result, we have learned to develop relationships with various systems that surround families and our treatment programs.
To the extent that we develop these relationships well, referrals can be more
appropriate for FFT, families can be better prepared by referring systems, and
the beginning of therapy can be smoother. Similarly, as we transition families
Pretreatment
System Linking
Referral,
Pretreatment
Assessment,
Linking
FFT Direct Treatment

Phases
Engagement
- Motivation
- Relational Assessment
- Behavior Change
- Generalization
Posreatment
System Linking
Boosters,
Referrals,
&
Linking
Youth / Family Management System(s):

-Juvenile Justice Legal
-Drug Court
- Welfare
-Mental Health
-Education
Figure 4.1. The big picture: Linking Functional Family Therapy with other systems.
Based on Alexander et al. (1983), Barton et al. (1985), and Waldron et al. (2001).
13190-05_P2-Ch04_2ndPgs.indd 70
2/8/13 11:04 AM
back into community systems, as we discuss later in this chapter, the better
the pretreatment linking is, the better we can help them maintain positive
changes long after FFT is complete. Educational, juvenile justice, and mental
health systems represent examples of systems with which FFT therapists link
often, and when those links are well developed, families are much less likely
to fall between the cracks.
Who Participates in FFT Sessions?
The decision about who participates in FFT sessions is based on an
understanding of which family members will be important in the therapy
process to begin change or hinder the process of change occurring with the
referred youth. It is seen as being a functional decision rather than based on
who lives in the home or whom everyone considers to be part of the family.
Information received at referral becomes crucial in aiding the process of making
this decision. It is important for communication to occur between FFT therapists and referral agents and systems to gather relevant information about the
referred youth and potential family members who may be involved.
FFT includes those family members who are believed to play a major
role in the dysfunctional behavior of the referred youth. These family members
include those capable of interfering with and willing to hinder the treatment
process and also those who are necessary to begin change in the referred youth.
In general, FFT includes parent figures, siblings, and other family members
(and even nonfamily members) who live in the home and who have regular contact with the referred youth. With respect to siblings, FFT ordinarily
includes preteens and older siblings who live in the household. When referral
information is ambiguous about such roles, especially regarding who seems to
impact the dysfunctional patterns that represent the raison dtre for referral,
FFT therapists attempt to bring everyone to the first session and then try to
sort it out if someone does not need to be there (e.g., individuals who do not
appear to be involved in the problem sequences).
A common challenge in determining who participates in treatment
sessions occurs in circumstances of blended, step, and divorced households.
Like all other aspects of the model, there is not an absolute rule that therapists
are expected to follow in these circumstance. Rather, therapists are expected
to determine what family constellations need to be included in treatment
and plan their sessions accordingly. We have observed that a wide range of
different constellations can lead to successful outcomes. For example, we
have conducted FFT sessions with two full blended households that included
four parent figures (mother, stepfather, father, and stepmother) and multiple
siblings and stepsiblings, with divorced parents and their children, and with
grandparents. All of these variations can lead to successful outcomes. Therapists
13190-05_P2-Ch04_2ndPgs.indd 71
71
2/8/13 11:04 AM
should be driving decisions about whom to include and making these decisions on the basis of their observations about who the necessary individuals
(and subsystems) are that are directly involved in the problem sequences.
Location of Services
FFT can be conducted in a variety of settings and locations. In particular, FFT therapists attempt to provide services in locations that will best suit
the needs of the family. The range of locations includes the office or clinic
setting of the provider site, the home, and a location within the community
where the family lives. The flexibility of therapists to be mobile in where
they conduct sessions becomes an essential component in the engagement
of family members in treatment. Many families are limited in their resources
for transportation. Therefore, it is important that the FFT therapist minimize
or potentially eliminate any transportation barriers that would exist for the
family members. For example, for a family that does not have a means of
transportation to attend sessions in the provider agencys office or clinic, the
therapist could conduct sessions at the familys home or in a local library close
to the familys home. The provider agency may also be able to provide bus
passes or tokens for public transportation to enable families to attend sessions
conducted in the office.
Number of Sessions by Phase
The average length of treatment in FFT is 12 to 14 sessions over 3 to
4 months, with an increased number of sessions or client contact for more
severe cases (e.g., gang involvement, parent psychiatric disorder). Once FFT
begins, the length of each phase is based on successful progress toward phase
goals and representative changes in within-family behaviors and interactions.
On average, we expect that the Motivation Phase is two to four sessions.
Then, consistent with earlier discussions and model depictions in which the
Behavior Change and Generalization Phases overlap, their representation
in sessions is best characterized as five to nine sessions in which the primary
focus is behavior change and an additional three to four sessions in which the
primary focus is generalization.
Therapists must tailor the length of treatment to the individual needs
and dynamics of each family. For example, in one family, intense conflict,
hostility, and blaming interactions may be significantly higher, so the therapist needs to spend three to four sessions in the Motivation Phase to create
a motivational context for change, whereas in another family that presents
with significantly lower levels of hostility and conflict, the Motivation Phase
may take only two sessions.
13190-05_P2-Ch04_2ndPgs.indd 72
2/8/13 11:04 AM
Timing of Sessions
The timing of sessions is a critical factor in FFT given the highly conflicted nature and risky behaviors of the family. In the early part of treatment,
the spacing of sessions should be considered along with the level of risk and
protective factors present within the family members and their relationships.
FFT looks for immediate change, first in within-family attributions and other
expressions of positivity, then in terms of more concrete, specific behavior
changes. With high-risk families, we have found that it may be necessary to
have more than one session per week during the first 2 weeks of therapy to
facilitate immediate changes in motivation and stabilization of the family.
The spacing or number of days between the first, second, and third sessions
depends primarily on (a) the severity of risk factors of the family members, in
their relationships, and in their ecosystemic environment; (b) the immediate
availability of protective factors and resources; and (c) the therapists judgment
of how long the family can maintain without a major conflict, crisis incident,
or disruption.
Increasing the density of services in the first 2 weeks with high-risk families
sets the stage for starting behavior change as quickly as possible. By rapidly
responding to the needs of the family with frequent and intense motivationfocused sessions, therapists immediately reduce negativity, enhance feelings
of hope, and establish working relationships with family membersall of which
set the stage for increased family member willingness to change the high-risk
behaviors that prompted the intensification of services. A benefit of tailoring
the density of services to family risk is that the therapist can maintain the
focus on clinical issues that underlie the problem behavior rather than be driven
solely by safety concerns or crises.
After the Motivation Phase goals have been met and the Behavior
Change Phase begins, sessions can be held once a week, and sometimes even
less frequently. Spacing sessions a week apart provides opportunities for family
members to begin to develop new skills and implement these new behaviors
in their relationships on a daily basis. Toward the end of treatment, in the
Generalization Phase, the spacing of sessions can remain at once per week or
be expanded to 2 weeks apart. The increase of days between sessions can allow
for ongoing skill practice and competence development, forced empowerment
and independence of the family from the therapist, and a focus on relapse
prevention planning for the family as a goal for the termination of treatment.
Booster Sessions
Booster sessions can be conducted as an extension of the Generalization
Phase. Booster sessions, whether conducted in person or via telephone, allow
13190-05_P2-Ch04_2ndPgs.indd 73
73
2/8/13 11:04 AM
the therapist to monitor family progress and to access or plan for the use of
any community resources that can help the family address new problems or
sustain prior gains. It is important that booster sessions be used as planned
opportunities to aid the family through the natural process of change, allowing the family to revisit previously learned skills and continue to apply them
to diverse situations and problem areas that arise in the future. Booster sessions
should not be seen as a new treatment episode. The FFT therapist should remain
focused on the use of learned skills and their application and maintenance.
Therefore, the number of booster sessions should be minimized, and the
length of time between treatment termination and potential booster sessions
should also be a consideration.
Flow of Treatment by Session
We offer the following template for the flow of FFT. In doing so, however,
we understand that these outlines and figure representations do not actually
tell readers how to do FFT. Consider an aviation metaphor: The runway is
solid and fixed in place, the aircraft is well designed and built, its systems are
functioning well, and there is sufficient fuel to land. However, crosswinds and
other weather factors still require considerable pilot expertise for a successful
landing. In this chapter, we have introduced the fixed aspects of FFT, but we
all become pilots when we enter a room with a family. We know where we
want and need to go, but we nonetheless require great skill to manage the
elements that can push us and the family off course.
Session 1
77
77
77
77
Begin the session by maximizing family members expectations

for change.
Continue to build relationships with all family members by
engaging in interventions that are relational and respect and
strength based and that attend to all family members.
Implement change-focus and change-meaning interventions to
reduce negativity and increase hope or positive expectations
for change.
Schedule the next session (within 24 days if necessary because
of high-risk factors).
Between Sessions 1 and 2

77
77
Review family members behaviors, feelings, and beliefs.

Consider and do your homework about additional possible
cultural match issues.
13190-05_P2-Ch04_2ndPgs.indd 74
2/8/13 11:04 AM
77
77
77
77
77
77
Identify unclear relationships within the family and with extended

family or other caregivers.
Identify resistance patterns of family members and caregivers.
Hypothesize relational functions for each family member.
Plan specific strategies to complete the relational assessment.
Plan specific therapeutic interventions (e.g., strength-based
themes) based on the above.
Contact representatives from the systems involved with the
family (e.g., child welfare worker, school officials and teachers,
probation officers, other treatment providers) to develop relationships and an understanding of their perspective and expectations
of case.
Sessions 2 and 3
77
77
77
77
Continue to build relationships with all family members by

engaging in interventions that are relational, that are respect
and strength based, and that attend to all family members.
Implement change-focus and change-meaning interventions
(see Chapter 6, this volume) to reduce negativity and increase
hope or positive expectations for change.
Assess relational functions by attending to the relational patterns
over time.
Reschedule the next session as needed (within 34 days with
high-risk families).
Between Sessions 3 and 4 (Usually 3 Weeks After Referral)

77
77
77
Assess progress toward completing Motivation Phase goals

(e.g., reduced conflict, increased hope, balanced alliances).
Develop intermediate and long-term change goals that address
family relational pattern deficits (e.g., problem solving, communication), parenting skills, and parent and youth well-being,
including specific issues such as posttraumatic stress disorder
and substance abuse.
Review and develop specific behavior change and educational
techniques that lead to intermediate and long-term goals as new
avenues to enhance all family members relational functions.
Behavior Change: Sessions 4 to 9 (1 to 3 Months Postreferral)

77
77
Apply behavior change techniques consistent with relational

functions of the family members.
Identify and address resistance to behavior change strategies.
13190-05_P2-Ch04_2ndPgs.indd 75
75
2/8/13 11:04 AM
77
77
77
Develop increased family initiative in behavior change and

continue to match relational functions.
Prompt, look for, and support appropriate family member
competence.
Assign homework for the family and follow through in sub
sequent sessions.
Generalization Phase: Sessions 10 to 14 (3 to 4 Months Postreferral)

77
77
77
77
77
77
Differentiate subsystems and specific individual issues (e.g.,

vocational deficits).
Engage in relapse prevention work.
Generalize specific behavior changes to other family situations.
Facilitate independence that is consistent with the relational
functions of all family members.
Maintain and create new links with extrafamilial systems to
generalize positive intrafamily changes.
Evaluate quality-of-life issues and plan for the future.
Termination Criteria
The termination criteria depend on the specific case and treatment system, as would be expected. Many referral systems ask only that the problem
behaviors (e.g., substance abuse) cease. Others ask FFT therapists to address
specific risk factors such as parental neglect and failure to monitor problem
behaviors such as truancy. In yet other circumstances, FFT therapists are asked
to report back to authorities (e.g., judges, case managers) regarding such aspects
of treatment as youth participation in sessions and missed appointments. In
all cases, FFT therapists work to clarify all such issues prior to or immediately
at the beginning of the first clinical session.
13190-05_P2-Ch04_2ndPgs.indd 76
2/8/13 11:04 AM
5
Engagement Phase
Engagement is the short and oft-forgotten or ignored phase of intervention. It is particularly critical when attempting to help traditionally
difficult to treat individuals and families like those typically addressed by
Functional Family Therapy (FFT). Undertaking FFT, or any other evidencebased therapy for that matter, without careful attention to system and family
engagement is not unlike painting the walls of ones house without preparing
beforehand. It is possible to simply open the paint container, grab a brush,
and begin painting. However, the process results in much better outcomes if
time and attention are devoted to preparationfor example, taping around
moldings and covering articles to protect them from splatters. In this chapter,
we present two critical aspects of the engagement process. In the first section,
we describe the framework and strategies for working with key systems that
youth and families are typically involved with at the point of initial referral
and over the course of treatment. In the second section, we describe the
DOI: 10.1037/14139-006
77
13190-06_Ch05_2ndPgs.indd 77
2/8/13 11:09 AM
goals, interventions, and outcomes that are involved in the engagement

process with youth and family members.
Engaging External Systems
FFT therapists receive referrals for youth and families through myriad
sources and contexts. These sources include probation and school counselors,
ministers or clergy, child welfare programs, other therapists, case managers,
pediatricians, and occasional self-referrals. Youth may be referred through complex multidisciplinary triage teams that have completed extensive documentation prior to referral, or they may be remanded to FFT treatment via judges
court orders. In other words, there is no standard way to launch the process of
linking a family to an FFT therapist. For the best family and youth outcomes,
however, FFT therapists and the programs in which they work attempt to establish positive links with every referral source and then respond immediately
to each referral. This creates both a tone and a process that enhance further
contact with the referral sources. The process also helps therapists obtain as
much formal and informal information as is legally and ethically possible. In
particular, it is beneficial to learn as much as one can about possible initial
impediments to beginning treatment successfully, including what times of
day are best and worst to contact family members. This effort is particularly
important in the case of family members who are likely to be resistant to
participating or who have jobs that might be compromised by calls during
work hours.
Over time, FFT therapists are able to develop relationships with personnel
within agencies or institutions that provide recurring referrals. FFT therapists
work to provide as much information about ourselves as possible to referral
sources to foster a sense of openness, collaboration, and willingness to provide
whatever assistance we can. Our responsiveness to the needs of the referring
agencies or institutions enhances the likelihood that these referral sources
will do everything possible to enhance families initial positive expectations
of us and what we do.
When FFT therapists work consistently with larger referral systems,
they first go to these systems and link with as many system-involved people
(stakeholders) as possible, including staff and directors from diverse agencies
and community representatives. Beginning with our early work with larger
referral systems (Alexander & Parsons, 1973; Parsons & Alexander, 1973),
we found that following through with the referring system, whether required
or not, is critical to maintaining referrals and support from such sources. For
example, we typically use procedures for obtaining written permission for
the release of information so that we can report that we have received the
13190-06_Ch05_2ndPgs.indd 78
2/8/13 11:09 AM
referrals. We may also, within the bounds of privacy and clienttherapist

privilege, provide referral systems with information about treatment attendance, progress in treatment, need for ancillary care, or other information the
system may need for its own monitoring and service provider responsibilities
and accountability.
This communication becomes tricky when the behavior of the youth
is the primary basis for referral. It becomes even more complex when youth
misbehavior elicits, occurs in response to, or is bidirectionally influenced by
the occurrence of parent problem behaviors. In family-based treatments, the
parents and youth often have their own support and oversight systems in place.
These systems involve their own legal constraints and histories that play
themselves out in parenting as well as in treatment processes.
A common example is a family of a youth referred to FFT for serious
behavior problems when a parent also is involved with a child welfare or mental health system. Often this involvement is the result of an abuse or neglect
history, substance abuse, or both. Many systems (medical, mental health, private groups, juvenile justice) already are involved in this family, and, unfortunately, such systems tend to be distrustful of each other.
Such multisystem involvement can become a major challenge not only
for FFT sustainability but also for the youth and families they presumably
are designed to serve. Unfortunately, there is no magic formula for how to
address these complex system relationships. Rather, addressing them successfully seems to involve the same core principles that guide all aspects of
FFT. These relationships, like all relationships, require attention based on
respectfulness, matching, and perspective taking. FFT therapists work to
understand individuals on their terms and with consideration of their pressures and constraints, then work with them so that the therapists needs (e.g.,
timely and positive referrals) can be in synchronicity with their needs. Over
time, of course, the most effective basis for the development of trust and
mutual support emerges from good (i.e., effective) work. Referral sources may
seem less than optimally forthcoming at first as they strive to protect the
interests of their clients, but when they benefit from significant decreases
in clients problem behavior (e.g., fewer court petitions, decreased drug use,
decreased domestic and other forms of violence, increased school attendance
and improved grade reports, increased employment, and increased satisfaction), they become increasingly supportive of FFT work and what is needed
for therapists to do it.
If FFT therapists do their homework and reach out respectfully to referring systems, they also can facilitate the process of engaging family members
to begin the treatment process. In turn, in the context of a positive referral,
the family members FFT therapists need to see are much more likely to be
available for the first session, ultimately providing better information about
engagement phase
13190-06_Ch05_2ndPgs.indd 79
79
2/8/13 11:09 AM
how to match the families culture and initial styles of relating to treatment
systems. This also helps therapists anticipate and minimize families initial
sources of resistance. All is not lost if the treatment process gets off on the
wrong foot, but the journey is more difficult and, with some families, may not
even begin.
Assessment: Pretreatment and During Engagement
Referral information is generally already available more or less extensively for youth and families. Sometimes this information consists only of a
name and a reason for referral (e.g., runaway, possession of drugs at school,
parent concern that youth is becoming uncommunicative, social services
receipt of referral regarding possible neglect). At the other extreme are cases
involving youth with extensive diagnostic test information and perhaps even
behavioral records in institutions and families with a history of many social
service contacts. FFT interventionists review such information, along with
as much demographic information as is available, to gain as much understanding as possible about the context in which intervention is to occur. For
example, is there information available that might facilitate cultural sensitivity, that might be informative about multisystem pressures (e.g., poverty)
and resources, and that might suggest individual constraints (e.g., learning
disability, illiteracy) that must be considered?
After initial pretreatment formal assessment, FFT uses formal assessment (e.g., diagnostic tests, formal self-report instruments) only when necessary to answer specific questions that cannot be answered in direct clinical
contact or when additional information necessary for legal or recordkeeping responsibilities is required (e.g., drug screens, documentation of reading
scores to establish improvement or appropriate school placement). Specific
agencies and systems, such as individual juvenile court systems, have added
their own assessment devices to meet their larger system needs, such as validating their own assessment instruments, relating youth characteristics to
census tract data, or providing diagnostic information to funding sources.
Finally, beyond the generic assessment typically obtained in educational, juvenile justice, and social service and mental health contexts, FFT
emphasizes the identification of the interpersonal impact of behavior on each
family member, at first only tentatively hypothesized on the basis of referral
information and reports of such colleagues as referring probation officers and
school personnel. As therapy unfolds, FFT therapists also engage in extensive
relational assessment, designed to provide them with a clinical road map for
how to organize behavior change interventions. In fact, therapists do not
undertake specific behavior change activities until they have at least a tenta80 functional family therapy for adolescent behavior problems
13190-06_Ch05_2ndPgs.indd 80
2/8/13 11:09 AM
tive picture of the relational impactthat is, the relational functionsof the
behavioral patterns that characterize the referred youths primary relationships. The relational patterns of parents and other highly influential people
in the youths life are, in turn, mapped in terms of how they fit and do not fit
the youth. Because of the importance of this construct, its operationalization
in FFT, and its role in guiding therapist activities, we discuss it separately, and
in detail, in Chapter 7.
Engaging the Family System
The goal of the Engagement Phase is to maximize family members initial
expectations of positive change. This goal is accomplished through (a) high
availability to meet with families at times and locations that are convenient
to them; (b) effective management of intake processes to present agency, self,
and treatment in a way that matches to inferred family characteristics; and
(c) presentation of treatment and self in a way that enhances family members
perception of the therapists credibility. In this section, we describe how to
accomplish these goals in FFT.
FFT therapists want to engage, at the outset of FFT, those believed to
be the major players in the youths referral and problem behaviors. Once
FFT actually begins, other individuals may be found to be highly involved in
the youths behavior, especially the problem behaviors, and therapists sometimes add them into the therapeutic process. In general, however, referral
sources are sufficiently involved and informed regarding the high-risk youth
and families they refer, and they can be quite reliable sources regarding the
first family treatment focus. For example, live-in boyfriends of mothers with
referred delinquent sons rarely offer to participate and, if asked to do so, often
respond along the lines of he wont listen to me...he isnt even my kid.
And sadly enough, many referral systems, including juvenile justice, often
do not even attempt to involve these live-in father figures, especially if the
adult relationships are inconsistent or conflicted or involve any substance
use. However, these individuals may have a significant impact on the referral
youth and other relevant family members.
For FFT, such situations are exactly the sorts of ecological contexts that
must be engaged from the outset to launch successfully a positive course of
treatment. This is especially important when relationships are loaded with
immediately proximal risk factors, flash points, and recurrent crises. Such
circumstances certainly loom large in the lives of many of our referred youth
and their parents or parent figures. So FFT therapists work very hard to find
a way to connect with them and engage them in the FFT process. Often this
involves asking, Would you be willing to attend one session so I can get a
engagement phase
13190-06_Ch05_2ndPgs.indd 81
81
2/8/13 11:09 AM
broader picture of what is going on? I think your perspective will be very valuable. Many treatment-resistant people are willing to come in when given
this message, whereas they are almost certain not to be willing to begin if
asked to come to therapy to help with James. Although it is certainly beneficial for them to attend more than the first session, they need to at least get
into a first session for the FFT therapist to begin to motivate them to come
back for more sessions. Stated differently, having an influential but highly
unmotivated family member in the first session at least gives FFT therapists
a chance to begin the motivation process with this person and to facilitate
system change. Referred youth do not live in isolation and often are in farfrom-perfect living situations. Thus whatever FFT therapists can do to see
parents or a single parent conjointly with the child from the outset of treatment is well worth the effort because family retention rates and ability to
move more quickly through FFT stages improve considerably. In particular,
having the parents involved from the outset allows the therapist to begin
quickly to incorporate the more powerful and long-lasting change-focus and
change-meaning techniques that are described in detail in Chapter 6.
Where?
Although FFT is most often conducted in the home or office, many
providers are able to be creative in going to and arranging family transportation to other venues. Over the years, alternative venues have included jails,
detention centers, residential treatment facilities of youth nearing release,
community shelters, and schools. Such flexibility can increase slightly the
cost of intervention but also increases dramatically the billable hours for
providers.
The First Call
With high-risk youth and families, first impressions count! The goal
in the Engagement Phase is to enhance the perception of responsiveness
and credibility and to demonstrate a desire to listen and help in ways that
match them. FFT therapists do not automatically adopt a particular style
when they call; an angry family member requires a different style than a
hopeless or frightened family member. The skills or qualities required during
this first call are simply the qualities consistent with positive perceptions of
clients, particularly persistence and matching. The focus during the first call
(and subsequent calls if necessary) is on the family members expectations,
and the goal is to be immediately responsive. The FFT therapists needs to
keep a strength-based relational focus, reflect a nonjudgmental attitude, and
demonstrate respect for individual and cultural characteristics and diversity.
13190-06_Ch05_2ndPgs.indd 82
2/8/13 11:09 AM
Schedule first sessions as quickly as possible and, again, offer to go to the home
if necessary.
The FFT therapist does everything possible to reach out to all relevant
family members, taking care not to demean, denigrate, or confront in the
process. Contact as many of the major player family members as possible
and attempt to send a very clear message that I am here to hear and respect
you on your terms first and foremost. Note that due to gender, age, cultural,
and ethnic differences, diverse FFT therapists engage and match to family
members differently depending on their gender, age, cultural, and ethnic differences. As soon as FFT therapists begin to get cues about youth and families
as individuals, they also add consideration of their cognitive and emotional
styles during their attempt to match them and who they are.
Beginning with the first call, good FFT is not linear or standardized.
The goal is to create the conditions necessary for all the key family members
to attend the first session. Engagement is not therapy; the only goal is to get
them into the session so therapy can begin. Keeping the focus this narrow and
specific enhances greatly FFTs success rate in getting started with the family
members needed on board to produce long-term change. Yes, engagement is
merely the first step in a challenging process, but without success in that first
step, the process begins in ways that limit greatly therapists ability to help
the youth and families referred to us.
We have found over the decades that FFT therapists are dedicated clinicians. Yet although mastering engagement would be easier with a protocol or
standardized set of techniques to use with family members from the very beginning of contact, such a prescriptive approach is not possible. All FFT therapists
begin the engagement process with a similar knowledge base regarding FFT,
and all (we hope) are passionately invested in engaging families successfully
in the change process and experience satisfaction when the therapy journey
begins successfully. At the same time, each call, colored by the therapists
style and set of skills, must be matched to the unique characteristics of each
family and family member and to the treatment setting. Above all, FFT therapists are clinicians who listen to the emerging details and challenges families
share as they work to schedule the first session and problem solve as flexibly
and creatively as they can within the structure of FFT.
Intervention Strategies of the Engagement Phase
Additional techniques include anything and everything that must be
done to get all of the major players together for that first critical session.
Often all that is necessary is for the therapist to match, listen, and present a
short, strength-based, positive message for all the major players to be willing
engagement phase
13190-06_Ch05_2ndPgs.indd 83
83
2/8/13 11:09 AM
to attend the first session. This process can involve various forms of what
may be flippantly referred to as schmoozing because the ultimate goal is
to present or position the therapist and treatment in a way that increases
the likelihood that family members will participate in the treatment process.
This involves working hard to cajole (respectfully), remind the resistant family members about how achieving the treatment goals will make their lives
easier and better, and listen for clues as to what would motivate the family
member to attend the session. For many therapists, this also can involve the
use of several change-meaning techniques, especially relabeling and perhaps
reframing, that they already use in the Motivation Phase of FFT. For example,
an exhausted and overwhelmed single mother might say, I dont think I can
do this anymore; hes exhausted me. He wont change anywayhis new family
is [gang name]. To this, the therapist might respond,
I can almost feel your exhaustion over the phone. This has been so hard.
But please tell me if I am wrong when I say that perhaps this is your way
of telling me that you are willing to let go a bit....You desperately need
help since you cant do it alone any more. If this is true, I am here for
youyes, here for [sons name] also, but for you.
In such a circumstance, the therapist likely will also need to contact the son
perhaps through the probation officer, or preferably directly with permission
from the officer:
Hello, [sons name]. This is Terry Z, and Id like to talk to you for a second
or two. I work for [agency name], and for starters, yes, Im White. I hope
that isnt too much of a problem, but if it is let me know, and Ill see what
I can do to find another therapist you feel more comfortable with. In the
meantime, Im worried about your mother since Ive talked with her. Im
also worried about you a bit based on what Ive been told, but I dont
know you at all, so you may change my mind about that. I like to not
worry. But I do know from the referral I got that you are in the spotlight
right now. If I may ask, how are you doing?
[Then soon thereafter:] Can I come over, or will you come and meet
me somewhere else with your mother? And, if I may, when I come to
[district name], I stick out like a sore thumbIm sure there is a younger
mans way of saying that. Do you mind if I call you right before I get there
so you can meet me outside, or would you rather I just come to your door?
In this example, the therapist adopts a one-down and respectful stance,

acknowledging that this is the gang members home (turf, etc.). Also,
although the therapist specifically refers to the mother as worried, this will
fail as a strategy if the youths relational function with the mother is extremely
autonomous (i.e., if he couldnt care less). Despite stereotypes, however, this
is rare. The appearance of not caring is common, but that veneer is one through
which a FFT therapist can intervene if he or she is successful first at engaging,
13190-06_Ch05_2ndPgs.indd 84
2/8/13 11:09 AM
then motivating, relevant family members. Also note that we dont ask the
youth to acknowledge his moms concern in our example; we just state it and
in our words and actions avoid taking sides.
In sum, during family engagement, the therapist uses every skill to get all
the major players together to work with them directly and begin immediately
the Motivation Phase. Such strategies as change focus and change meaning
(see Chapter 6) can and should be used if necessary. However, they are not
explicitly prescribed for the Engagement Phase because, strictly speaking,
they arent necessary for successful engagement, whereas they are necessary
and clearly prescribed for the Motivation Phase.
As a matter of course, FFT therapists line up their immediate in-session
goals, their intermediate end-of-session or treatment-phase goals, and their
long-term outcomes. By no means is this a simple linear progression, but it
does represent a coherent sequence of implementation steps with families. For
example, in FFT with gang members, therapists do not simply jump directly
into changing the referral behaviors despite the intense pressure on them
to address the most pressing risk factors directly and immediately. Instead,
they first pave the way by engaging family members in treatment. Then they
quickly begin inducing or motivating family members to change by creating a
context that is less negative and even hopeful. They also must assess how the
referral problem behaviors relate to the rest of the familys relationships and
needs (relational assessment) before they can undertake the powerful change
trajectories that will be necessary.
engagement phase
13190-06_Ch05_2ndPgs.indd 85
85
2/8/13 11:09 AM
13190-06_Ch05_2ndPgs.indd 86
2/8/13 11:09 AM
6
Motivation Phase
Creating a motivation context for change in the initial sessions is fundamental for subsequent behavior change. That is, motivation represents the
gateway for lasting change. For this reason, we have front-loaded Functional
Family Therapy (FFT) with numerous techniques and strategies for negotiating interactions with family members in these critical early sessions. In this
chapter, we describe the goals and tasks of the Motivation Phase, including an
overview of the interpersonal characteristics and the overarching strengthbased relational framework that pervades interventions in this phase. We
also describe specific interventions for achieving the goals of the Motivation
Phase and provide examples of each technique.
DOI: 10.1037/14139-007
87
13190-07_Ch06_2ndPgs.indd 87
2/8/13 11:09 AM
Goals and Tasks of the Motivation Phase

Beginning with the first direct contact with family members, therapists
systematically and contingently intervene to achieve the specific goals of
77
77
77
77
establishing balanced therapeutic alliances with individual family

members;
reducing negativity and blame;
instilling a sense of hope (e.g., I have something to gain by
being a part of this process); and
creating a family focus, rather than an individual focus, for both
problems and strengths.
When they begin therapy with FFT therapists, family members have
developed rigid or defensive cognitive schemata through which all information
is filtered. These views influence and sustain the highly coercive and defensive
interchanges that serve to further solidify individual family members negative
attributions and blame. Over time, these interactions become so familiar and
habitual that they are virtually automatic.
The notion of automatic processing provides a useful nonblaming perspective for understanding family communication processes. Take an example
from everyday life. Can you remember when you first learned to drive a car?
Every action required considerable planning and thought, and for all of us,
learning to drive a car required all of our mental resources. With experience,
however, many of the tasks that once required complete focus and attention
could be accomplished with little thought. What required our full attention
at one point has become so habitual that it has now become automatic, and
we often are not even aware of the cognitive processes involved. Recurrent
negativity, in the families we see clinically, seems to operate in the same way.
Disrupting such repetitive negative interactions and their representational schemata is a critical first step in the FFT treatment process. The goal
is to first intervene in the moment to create a different experience that disrupts the familys automatic responses. This then allows for more controlled,
deliberate, or thoughtful processes. Initially, the disruptions may be accomplished by simply interrupting family members, but because the FFT therapist
cannot keep intruding alone, he or she must quickly transition into intervening in ways that build relationships and consistently introduce a strengthbased, relational focus into the session. As interventions become more complex
and involved, and as therapists builds relational capital (i.e., better therapeutic alliances) with family members, they are then able to take the initiative to introduce new ideas into the session. Often, these ideas would have
been rejected prior to the introduction of a strength-based, relational focus.
Over time, however, family members individual blaming attributions are
13190-07_Ch06_2ndPgs.indd 88
2/8/13 11:09 AM
transformed in such a way that family members gain a renewed sense of positive and adaptive connection to each other as well as the experience that
change is both possible and worthwhile.
Thus, at this early juncture in the treatment process, the intent is not
necessarily to change attitudes, attributions, or other cognitions but rather
to disrupt rigid, negative patterns and create an opportunity for family members to experience that something new and more hopeful is possible. Specific
techniques are designed to reduce family negativity and create positive and
balanced alliances in which each family member feels that the therapist sided
with him or her and each experiences that there is something personal to
gain by participating in treatment. In addition to the specific techniques we
describe in detail later in this chapter, therapists accomplish this through
adopting an overall nonblaming relational role in which family members
experience that the therapist is more interested in hearing and respecting
family members than in examining what they do wrong or how they need to
change to make things better. At the conceptual level, what holds the skills
and techniques in this phase together is a persistent strength-based and family relational focus through which family members experience one another
in new and more adaptive ways.
Therapist Characteristics: Adopting
a Strength-Based and Relational Focus
The emphasis of FFT in the early sessions is on creating a context in
which family members begin to experience one another in new and more
positive ways. The most immediate goal is to systematically replace negativity, blame, and hopelessness with a strength- and relationally based focus
that introduces more positive and adaptive attributions and emotional links
within and between family members. The strategies therapists use are relationally real, powerful, and often unexpected by families who are used to
problem-focused (and even blaming) interventions from the service providers or systems with whom they have had the most frequent contact.
Over the years, we have found that in diverse treatment populations,
agencies, and treatment contexts, the immediate Motivation Phase interventions are as much about therapist attitude as they are about specific techniques. Fundamentally, therapists must believe in and be committed to a
relational and strength-based approach, even when positive strengths and
goodwill in the family are not at all apparent. Part of the challenge for therapists is reflected in the intensity of the behaviors that often bring families
to treatment (e.g., verbal and physical abuse, neglect, rejection, abandonment, sexual abuse). These behaviors can push therapists personal buttons
motivation phase
13190-07_Ch06_2ndPgs.indd 89
89
2/8/13 11:09 AM
or elicit responses that pull them away from their relational goals, thus going
far beyond the traditional construct of countertransference.
Facing such behaviors, therapists can fall into the trap of taking sides or
challenging a maladaptive behavior to protect a vulnerable family member.
Quite often, these natural and even understandable tendencies on the part of
therapists lead to interventions that support and validate one family member
but blame and distance another. A therapist may engage in a disproportionate
amount of supportive interventions toward the family member whom they see
as being the victim in the current situation. Or, just as commonly, the therapist
may directly challenge bad behaviors of the family member they view as being
the perpetrator or instigator in the family. In either case, specific interventions
can become individually focused and, to some degree, confrontational, which
our research and clinical experiences have shown results in immediate negative outcomes such as increased within-family conflict, resentment, walking
out on the session, and dropout.
In FFT, a strength-based, positive enhancement of family relationship
issues pervades all interventions, from simple acknowledgments to development of complex themes. With respect to the former, for example, a
therapist may go beyond a simple individual-focused acknowledgment of
a mothers negative feelings (It sounds like you feel hurt) to include a
relational focus (This seems to have hurt you even more because you have
such special feelings for your son). Both acknowledge negative feelings
and serve to help build an alliance with the mother, but the latter statement
acknowledges both her negative feelings and the special feelings she has for
her son, feelings that are often hidden or disregarded when negativity and
hostility emerge in the family. This shift to a benign relationship focus is at
the heart of the specific Motivation Phase interventions described in the
next section.
The implementation of these interventions requires that therapists have
considerable relationship and interpersonal skills to build alliances with individuals who are often in overt conflict with one another. Just as important,
therapists must be able to interact with family members in a nonjudgmental,
accepting, nondefensive way, even when family members are doing or saying things to one another that pull the therapist into the system to protect,
defend, chastise, or take sides with individual family members. Therapists
must have considerable courage and resilience to stick with this relentless
relational focus in a way that is sensitive to the diversity of individuals and
issues presented in the context of treatment.
We have coined the phrase fearless empathy to describe the approach
that therapists must take to deal with negative, helpless, hopeless, and other
wise dysfunctional families. Empathy begins with sending family members
13190-07_Ch06_2ndPgs.indd 90
2/8/13 11:09 AM
the message that the therapist is totally committed to understanding their

inner world. It is important for family members, particularly those of different
gender, socioeconomic status, religion, and the like, to experience acceptance from the therapist. Relational empathy allows therapists to send such
a message without having to agree with, accept, or like the (sometimes very
destructive) ways family members express these inner worlds. It is important,
therefore, for the therapist to be aware of the potential biasing influence of
his or her own background and to avoid the possibility of confounding the
values held by the family within their culture and ethnicity.
The second component, fearlessness, involves sending the message that
the therapist is not personally overwhelmed, shocked, frightened, disgusted,
or intimidated by the intensity or nature of family members emotions and
attributions. The therapist must send a tacit yet unequivocal message that
I hear your pain, your badness, your intense anger, and I will be here with
you. We will deal with this together. Imagine, for example, that a child
in the session is considering sharing with the therapist the fact that abuse
occurs. Then imagine that this child sees the therapist beginning to exhibit
defensive behavior, anxiety, or otherwise avoidant reactions to a parent when
the parents negative affect begins to increase in intensity. Certainly such a
reaction would not provide the child with a sense of safety and comfort. Or
imagine a response to the depressive ideation of one family member. If the
therapist immediately begins talking about hospitalization or medication,
the family is not given the sense that alternative communication or other
behavioral strategies are available. Thus, it is vital that the therapist has
nonavoidant ways to deal with intensely negative and disturbing thoughts
and feelings. The techniques described in the next two chapters provide
therapists with systematic ways for responding to family members, even in
the most difficult situations. The relative simplicity of some of our changefocus techniques can also make it easier for therapists to use these strategies
to tread water in the session when they are not sure what to do next. In
this way, the FFT model provides a sophisticated yet easily applicable road
map that therapists can use to maintain consistency and focus at all times
with family members.
In sum, the therapists role is to help family members experience one
another in new, less destructive, and more hopeful ways. This requires creativity, a willingness to introduce new perspectives and frames, and the flexibility
to approach conflict in many different ways until the therapist gets something
that sticks (e.g., that creates hope). Telling it like it is, especially in families
characterized by destructive relationship patterns, often is far less effective
than creating a warm illusory glow that can break temporarily the cycle of
hopelessness and destruction.
motivation phase
13190-07_Ch06_2ndPgs.indd 91
91
2/8/13 11:09 AM
Specific Intervention Strategies

in the Motivation Phase
In FFT, the family systemic and relational interventions of the Motivation
Phase are organized in two broad domains of clinical techniques: changing
focus and changing meaning. These techniques are summarized in Exhibit 6.1.
Change-Focus Techniques
Change-focus interventions are intended to disrupt negativity and unproductive family interactions by shifting, stopping, or redirecting communications. Change-focus interventions are relatively simple interventions to
implement and are often used when the therapist is still getting a sense of
how to effectively intervene with the family but recognizes the need nonetheless to address negative behaviors in the session. These techniques reflect
a persistent therapist-driven attitude to move the family from an individual, blaming, and negative focus to a nonblaming, relationship focus in
the session. They typically are brief, focused, and contingently delivered in
response to specific behaviors in the session. The intent of introducing them
is to block, interrupt, or prevent negative interactions or to reinforce positive
communication or family strengths.
DivertInterrupt
The most basic of the change-focus techniques involve diverting and
interrupting escalating negativity and blaming behavior during sessions.
Although the techniques are simple, disrupting family members negative
interactional sequences through divertinterrupt techniques represents
a major interpersonal maneuver that helps families de-escalate their toxic
negativity. Therapists divert family negativity when they intercept a negative
speech act made by a family member instead of allowing the family member to whom it was directed to answer. Therapists interrupt family negativExhibit 6.1
Major Clinical Techniques in Functional Family Therapy: Motivation Phase
Change focus
Interrupt and divert
Point process
Sequencing
Selectively attend to positive elements
Strength-based relational focus
Do somethingTake a risk
Change meaning
Relabels theme hints
Theme hints
Reframes
Reframes + (noble intent)
Themes
13190-07_Ch06_2ndPgs.indd 92
2/8/13 11:09 AM
ity when they do not allow a family member who is making a negative or
defensive speech act to complete a blaming diatribe. In our prior research, we
have found that if a therapist simply diverts or interrupts a family members
negative speech act, then the subsequent family members speech act is almost
twice as likely to be positive than if the therapist allowed the family member
to respond to the negative statement (Robbins, Alexander, & Turner, 2000).
It is important to note that divertinterrupt techniques are not defined on
the basis of the content of the therapists verbal behavior (as is the case for the
change-meaning techniques described in the next section). That is, regardless
of what the therapist says, therapist behaviors are considered to be divert
interrupt whenever a therapist disrupts negativity by intercepting, blocking, or
redirecting communication. Divertinterrupt interventions require an active
and involved therapist who is highly attuned to the meaning and nature of
interactions in the family. Therefore, these interventions are used in a manner
that is sensitive to the current interactions, and although they involve interfering with or speaking over family members, they are delivered in a manner that
is respectful and accepting of the family.
Pointing Process Technique
Pointing process involves commenting on interactions or events that
occur during therapy sessions. As FFT therapists share their observations and
attend to each family members report about family processes and extrafamily
interactions, they can comment on the process of how family members relate
to each other, thereby making explicit the interrelatedness of family members feelings, thoughts, and behaviors. However, rather than simply describing interactions that are characterized by negativity and blaming, therapists
selectively choose nonblaming, preferably strength-based descriptors. This
can serve to defuse or at least lessen negativity by shifting the focus from the
specific content being discussed to the relational aspects that underlie it but
are hidden from family members in the current moment. In a session with one
family, for example, the therapist made the following comment to the father:
I noticed something Id like to check out with you. When you talk to
Tommy, you tend to lean forward a little bit, whereas with Chris, you
often point toward him with your finger. I cant figure out if you think
Chris wont get the message if you dont emphasize it, or if you are already
discouraged because you think he wont pay attention, or maybe you
point to let him know that reaching him is still very important to you.
Maybe the three of you know how to interpret all this, but Im still trying
to find out how this works for you.
Pointing process interventions can involve complex or simple

observationsfor example, I notice that every time you start to talk about
your struggle with depression [to mom], he [target adolescent] makes a joke or
motivation phase
13190-07_Ch06_2ndPgs.indd 93
93
2/8/13 11:09 AM
teases his brother. In either example, pointing process serves to take the focus
off an individuals behaviors to instead focus on connections or relational processes between family members. The content of these interventions can be
useful for developing alternative hypotheses about the meaning of behaviors.
For example, the therapist might follow the basic observation noted at the
beginning of this paragraph with a more complex question or observation that
draws attention to the youths connection or sensitivity to his moms pain.
Sequencing
The change-focus technique of sequencing involves examining repeated
patterns of behavior that occur within the family, such as arguments or other
manifestations of conflict between family members. Sequencing differs from
pointing process in that the latter refers to interactions that occur in front
of the therapist. Although sequencing often is used to assess what happens
with regard to the specifics of a presenting problem, it can be applied to a
wide variety of issues or complaints the family brings to the session. In fact,
sequencing often can be introduced simply to create a positive tone as context for subsequent interactions in a session. The therapist often begins with a
series of questions such as When did this happen? How did it start? What
happened next? and, to a seemingly uninvolved family member, Where
were you when all this was going on?
Because information is drawn out in a sequential and circular fashion,
families are helped to see more clearly and experience the context in which
behavior occurs. To the surprise of family members, asking about who was not
involved in a problem sequence often can open up new avenues for exploration
or change. For example,
Therapist: So, Rubn [son], you walked in an hour after curfew, and
you two [mom and son] report things got out of control very
quickly. Right so far? [Mother and son nod.] Now [to stepfather], Toms, did you see or hear any of this? Where were you?
Mother:
[rather than stepfather, with a tone of annoyance]: Working,

as usual!
Therapist: Oh, as usual, eh? [To mother] Do things go differently

when he is around rather than working?
Mother: [still seeming to be annoyed]: Oh, yeah. He [son] acts like
an angel then, and Toms assumes Im either exaggerating
or the cause of the whole thing.
Therapist: Ah, OK. And Toms, I want to ask you if it seems that way
to you also, but first I want to ask Rubn. Rubn, your mom
seems to think you act differently when you are alone with
her rather than when Toms is around. Are you aware of this?
13190-07_Ch06_2ndPgs.indd 94
3/11/13 2:01 PM
This sort of sequencing expands the focus from one individual, or in

this case a dyad (motherson), to include a family member who was not
even present. This can help family members become aware of aspects of their
relationships that were not previously in their awareness or that they did
not see as directly related. In some cases similar to the above, sequencing
has opened up relational issues that were central to the family and that also
allowed the therapist to reframe the problem youth in a much more benign
way. Reframing receives much more elaboration below, but the following
example demonstrates how the various techniques of the Motivation Phase
can work in a synergistic manner:
Therapist: OK, let me take a break here and run something by you.
Rubn, you are the one who got us all here, right? I mean,
you were what the referral was all about. [Rubn gives a
small nod.] However, Im getting this sense that rather than
being the major issue in a problem sense, you might be trying
to do something very good for your family. [Such comments
often elicit startled looks because they are so divergent from
the usual problem-kid focus.] If I follow this, your mom and
Toms may be still working out their own deal....How
long have you two been together?...Well, I gotta tell
you, Rubn, that sometimes when a couple gets together
after there are kids already involved, like in your family,
they never get a chance to figure out their own deal. For all
Iknow, your mom may not be happy with your dad [notice
the therapists switch from the stepfathers first name to the
role of dad] working so much. She may like the money but
kind of wishes he was home more to help out with you. So,
as strange as it might sound, maybe you somehow know this
and are causing trouble so your mom can try to renegotiate
with Toms to be home more. Does this make any sense at
all? [Therapist looks around at all three family members.]
Whether or not this represents a fruitful change in focus in this early

session, it demonstrates how something as simple as sequencing an event that
occurred at home can be turned into a larger family and relational frame. It
also paints Rubn as possibly being something other than simply a problem
adolescent whose behavior requires intervention. Further, as we have learned
from social psychology and other disciplines, even if the possible interpretation offered by the therapist is rejected, the family members schemata with
respect to each other have been impacted. As we have repeated already, no
single intervention will by itself produce major changes in problem behaviors, but a change in schemata can allow for much more successful behavior
changes to be initiated when FFT moves to the next phase of behavior change.
motivation phase
13190-07_Ch06_2ndPgs.indd 95
95
2/8/13 11:09 AM
When a sequence is completed to include what occurs before, during,

and after an event, there is often an identifiable outcome that can be tied
to a theme or function of the participants (see the Reframing and Creating
Themes sections below). When used in a relationally focused and nonblaming way, the focus of sequencing is not on the content or problem that
occurred but rather on family relationships and the meaning of relationships
and behaviors to individual family members. For instance, when a dad steps
in to harshly punish his son after the son has talked back to his mother, a
problem focus would be a focus on understanding why the sons behavior was
disrespectful. In contrast, an FFT relationally focused sequencing intervention would focus on framing the dads actions as a way of protecting and
supporting the values of the family. The father can feel acknowledged for
having a positive intent, even if his way of doing it might have been harsh
and nonproductive. Sequencing thus reveals family patterns that lead to
either positive or negative familial outcomes, and when a sequence can be
drawn on paper, it can in itself act as a reframe (see below), particularly when
the sequencing is accompanied with nonblaming, contextual description.
Sequencing also occurs when therapists focus on adding depth to sequences
that result in positive behavioral outcomes.
A beginning therapist may find the concreteness of sequencing helpful
in many ways. New therapists can use sequencing as a way to structure and
guide the session. Armed with what, when, and how questions, therapists
can easily track the therapeutic discussion and insert a pervasive relationship focus into the session. Raw data collected about family interactions
is useful for formulating hypotheses around themes and functions. When
the therapist collects this information for a sequence, it tends to be a fairly
reliable description of family interactions. Sequencing also is more likely to
include the relational rather than individual focus, which is associated with
positive outcomes (Jensen, 2008). However, therapists must avoid confusing
what family members say about a behavior with the actual behavior. In addition, it is important to stay focused on asking family members about specific
behaviors, such as by asking What did you do? or What happened next?
as long as such questions are not likely to produce increased blaming and
other forms of negativity.
Systematically Attending to Positive Elements
Families communicate a lot of information during treatment, much of
which is loaded with negativity. However, even in the families who demonstrate considerable negativity, there are at least some statements or sentiments that are positive. Sadly, however, these sentiments are overshadowed
by negativity, and it is easy for therapists to become trapped in focusing on
problems and blame. Experienced therapists, with an intent to look for posi96 functional family therapy for adolescent behavior problems
13190-07_Ch06_2ndPgs.indd 96
2/8/13 11:09 AM
tive elements, are able to process information rapidly and not miss the subtle positive messages that are often embedded in the negative interactions.
Sometimes positivity is not embedded in the negativity, but the therapist
can work to infer or imply it might be. Stated bluntly, it is our job, not the
familys, to seek out and develop hope and more positive attributions. From
the familys perspective, our seeing more than the negative statements is the
first step in a healing and transformational process both in the moment and
for the future. These interventions thus serve to broaden family members
narrow focus to include their positive views about themselves (especially in
the case of depression) and other members of their family. This, in turn,
develops a more positive go-to place for the family as members experience
new challenges.
An example would be a sons interruption of a statement being made
by the stepfather:
Stepfather: Hes been this way before I ever set foot in this house. His
mother told me he was even like this with...
Son:
[interrupting]: Oh, bullshit! You wont own up to anything!

You come in thinking you know everything, but you dont
know shit.
Therapist:
Wowthat was clear! Let me get this straight. Mr. X, did you
notice how quickly Daniel jumped in to correct you? I agree
it was rude and argumentative, but he gave you a clear invitation to get more information before you said anything else. So
if I may, Daniel, what is it that your stepdad doesnt know?
The therapists interruption served to break up a possibly intensifying interaction, and rather than focusing on the rudeness of the sons interrupting, it
instead asked him for more input. This is consistent with the therapists goal
of creating a tone of inquisitiveness rather than blaming.
When therapists are uncertain about how to interrupt and divert a
negative interaction as it unfolds, it is important to remember that not all
of the behaviors on which a therapist can comment are verbal. Therapists
should pay attention to facial expressions, meaningful looks between family
members, and sequences (who follows whom?). Many of these can be used
in the moment to refocus interactions onto positive elements. For example,
the therapist may remark, When your son was talking, I thought I might
have seen how proud you were that he was able to stand up for himself. Or,
I noticed that every time he gets angry, you adjust your tone and speak more
quietly and in a soothing way. Systematically focusing on positive sequences
creates a working climate in the session in which family members gain a new
perspective about themselves and each other. Again, the lens is shifted from
the negative behaviors and problems with which families enter treatment
motivation phase
13190-07_Ch06_2ndPgs.indd 97
97
3/11/13 2:01 PM
to the positive aspects of relationships that have been overwhelmed by the

negativity.
It should be noted that selectively attending to positive elements does
not consist of viewing family members through rose-colored glasses. The elements that are attended to in these interventions are actual aspects of family
interaction that get lost in the intensity of the anger or negativity of the
moment. And they are not intended, nor should they be allowed, to excuse
bad behavior! Therapists must be careful not to simply gloss over negativity and highlight the positive aspects of communication, and FFT therapists
should develop a consistent strategy of acknowledging negativity before shifting to the positive elements.
Strength-Based Relational Statements
Strength-based relational statements include interventions that ascribe
a positive or even noble attribution about one persons efforts to another person. This includes seeing the positive side of apparently negative relational
patterns. For example, to a parent and child who are beginning to argue
loudly with each other,
OKIm going to jump in here for a second. You both are angry right
now, and pretty much yelling. Im sure that at times you or someone
else wants you to stop yelling. But for now, I want to note that you seem
relationally on the same pageno one seems to be holding back much,
and both of you are honest in expressing your anger. Lots of families tend
to go underground with their anger, but with you two, it seems that I can
trust that you will bring it out and deal with it directly. That gives me
something to work with that often I dont have. Now, I wonder...
In another instance, instead of acknowledging a moms anger about

her daughters truancy by simply stating I can hear how angry you are, the
therapist may rather state, Your exasperation is even more difficult for you
because you have such high expectations and ideas for how she can excel
in school. Both interventions serve to acknowledge the moms anger, but
the latter goes further by highlighting the strength-based aspects evident in
moms anger.
Do SomethingTake a Risk
Having provided a number of strategies and guidelines, we remind readers at this point that there are no absolute rules in FFT. At the same time,
troubled families do tend to behave in ways that are predictable, and we
have all heard the universal truth that the best predictor of future behavior
is past behavior. The families we see usually are characterized by stable and
predictable patterns, even if the stable pattern is one of instability. When
13190-07_Ch06_2ndPgs.indd 98
2/8/13 11:09 AM
the instability becomes predictable, as is often the case in families we see, it

becomes one important family pattern that we must help change in a more
productive and positive direction. In other words, therapists should not be
fooled by referral terms such as unstable family; this very quality both endures
and keeps them in trouble. Also, in general, the more closed the family system, the more rigid and narrow the pattern. Outside influences such as gangs
and oppressive work schedules are problematic, but other, positive system
influences (e.g., educational, legal, spiritual, medical) are, in fact, essential
to the health of families.
Of all possible interaction patterns or exchanges in families, the one
consistently observed in reality is that negativity begets negativity. In families with a delinquent youth, once negativity surfaces, family members are
quick to respond in kind with their own negativity, and the cycle then escalates, often with increasingly shorter latencies, with each new statement or
behavior. Given this predictability, our philosophy in FFT is that it is the
therapists responsibility to do something or take a risk in the session. Sitting
back and listening or even just commenting will not change the pattern. It
is up to usas agents of changeto be active in creating a different experience. In FFT, we consider ourselves bound by our commitment to at least try
something new, and the sooner, the better.
Facing this challenge, it would be nice to say that once therapists have
mastered FFT, they have a sense of where they are and where they are going
at each moment in treatment. Unfortunately, this is not the case. We all
encounter situations in treatment that confuse or challenge us. With experience, however, comes acceptance that it is all right to feel lost at times. The
change-focus techniques described above do not require us to understand
exactly what is happening in the moment. In fact, many of these techniques
can be used to stall for time when we do not know what to do next, and we
can still move the family forward. The nonblaming and relationship focus
of motivational techniques helps facilitate the change process by disrupting
negative family interactions even when we are not certain what to do next.
This gives therapists some breathing room in which they can develop more
impactful positive change interventions.
Change-Meaning Techniques
Change-meaning techniques represent more complex interventions that
can help therapists build new and positive momentum while still in early FFT
sessions. The goal of their use is the creation of new, nonblaming, and even
noble attributional frames for family members behaviors. Like change-focus
interventions, change-meaning techniques are intended to disrupt negativity and unproductive family interactions. However, as their name implies,
motivation phase
13190-07_Ch06_2ndPgs.indd 99
99
2/8/13 11:09 AM
change-meaning techniques also involve attempts to create a positive motivational context for change by altering the meaning of how family members understand and experience themselves and each other. To use a parallel
example that many nonproblem families experience, even fit and nonsmoking people understand that regarding smoking and unhealthy eating
patterns, people easily become engaged in the desire and even commitment
to change. However, maintaining the change, which is notoriously difficult
to do, requires much more than initial superficial or fear-based motivation.
Change-meaning techniques address those more complex and important levels of motivation everyone needs to undertake difficult change journeys.
The in-depth descriptions of change-meaning techniques described in
the rest of this chapter are based on decades of clinical research and experience. The categorical nature of these descriptions is helpful in understanding
the FFT model, but they do not necessarily reflect the moment-to-moment
thought processes of therapists as they are matching interventions to the
unique needs of individuals and families. Therefore, therapists are not necessarily expected to use all of these techniques all of the time. However, by
being precise at the training or learning stage, we hope to provide sufficient
detail to help therapists integrate and use a range of change-meaning techniques with difficult families.
Theme Hints
Theme hints are therapist interventions that telegraph or represent a
more complete nonblaming relational theme. For example, in response to a
youths inappropriate behaviors in the session when his mother and father
begin to fight, a therapist might use a theme hint about the meaning of his
distracting behaviors by saying, You seem to have a protective streak in
you. In this example, the theme hint is protection. However, the theme is
not fully developed or linked in relational ways to other family members or to
problematic relational sequences. Nonetheless, a theme hint can lead family
members to look at the therapist in wonder or even confusion. If so, it has
done its job: It has disrupted the escalating argument and opens a window for
a therapist intervention without it having to be as intense.
Another example can be found in our work with a mother and her
16-year-old son, who were arguing about the son not attending his older
brothers college graduation. The mother said, He lacks compassion. You
know? He just lacks what most humans have. He has no feelings. The therapist responded by saying, As a mother of both kids, you are in a very complicated situation. The mother immediately acknowledged the trap she felt
she was in (implied in the therapists statement) by saying, I love both my
kids, and I saw this as a chance to bring our family back together again. The
theme hint did not change the fact that she was angry about her sons behav100 functional family therapy for adolescent behavior problems
13190-07_Ch06_2ndPgs.indd 100
2/8/13 11:09 AM
ior, nor did it directly address or challenge her views that he lacks compassion; rather, the therapist shifted the lens to focus on her role as a mother
to both of her kids. In this case, doing so evoked a more nurturing, adaptive
statement (I love both my kids).
Relabeling
Therapists relabel by reflecting to family members a similar, but less
harmful, explanation for a behavior in which they have engaged or are
engaging. The goal of relabeling is to shift some of the negative intensity in
the meaning of that behavior. Consider a teenage sons complaint about his
mother arising in an early sessionAs soon as I walked in the door, she just
went off on me!and the therapists response, So she let you know right off
the bat that she had an issue with you. Although these statements may seem
quite similar, she just went off conjures up a more intense image than she
let you know right off the bat that she had an issue with you. This relabel
also added a softer relational component (she had an issue with you) rather
than the more attackervictim tone of she just went off on me. Relabels also
represent an intervention style that families generally experience in more
positive ways than therapist interventions that amplify the negativity with
which they already struggle. In addition, they do not involve any element of
blaming or suggestion that the behaviors will need to change.
Reframing
Reframing is generally described as a technique, and although its elements may differ across therapy models, the process of reframing seems to
transcend most family-based intervention models. Many models, in fact,
consider it a core technique for all family therapy approaches. As defined
by Watzlawick, Beavin, and Jackson (1967), a reframe is a change of the
conceptual and/or emotional setting or viewpoint in relation to which a situation is experienced and to place it in another frame...and thereby changes
its entire meaning (p. 95). Reframes, as defined in FFT, add two components to the change-meaning process: acknowledgment of the negative and
proposal of a possible alternative (and perhaps even benign) motive. These
components add significantly to the therapists ability to reduce family negativity while maintaining an overall nonblaming relationship with all family
members.
Reframes include a clear acknowledgment of the negative aspects of a
behavior (thereby supporting the people who are negatively impacted by the
behaviors in question). However, the acknowledgment does not include an
agreement with the family member. Rather, the focus of the acknowledgment is
to establish that the therapist is attuned to and understanding of the relevance
motivation phase
13190-07_Ch06_2ndPgs.indd 101
101
2/8/13 11:09 AM
of the negative behavior or problem to the family member. Acknowledging

the negative involves patience and skill, and new therapists often struggle
with this acknowledgment process because they move too quickly to try to
influence change. More experienced therapists, however, realize that these
interventions serve as the foundation for what is coming next. There is an
appreciation of the sequence of change. Therefore, more experienced therapists are not threatened by intense expressions of negativity and emotion
in the moment but rather embrace this process by spending adequate time
acknowledging and respectfully responding to family members in relational
ways. This requires trusting the process and recognizing that the intensity of
negative emotions that are being expressed represents only one snapshot in
time of a swinging pendulum: The higher the upswing on the negative side
of the arc, the higher the potential for positive change when the momentum
shifts in the other direction. Acknowledgment represents the first step in
embracing the arc and then using its momentum to push the pendulum in
the other direction with new relational reframes and themes.
After the acknowledgment of the negativity, therapists then offer an
alternative attribution about the person who engaged in the behaviors.
The alternative attribution suggests the possibility of a less negative interpretation about the actors motivation. For example, in the example used
in the Relabeling section above, a therapist may say, So, when you entered
the room, you immediately had to face the anger [this acknowledges that
the behavior was negative], which Im guessing was probably motivated
by [to mother] your feeling worried, frustrated, perhaps even frightened by
what you think might have been going on with your son. This reframe
acknowledges but then moves the focus from the overt negative behavior
(went off on me) to the mothers possible motive of expressing hopelessness and frustration. This generally allows the therapist to think (and talk)
about relational issues rather than behavioral issues.
Enhanced ReframingReframe +
In our experience, the most powerful reframes acknowledge negative
behavior, but rather than offering an alternative neutral or benign motive
for the behavior (e.g., moms frustration), the hypothesized motive is labeled
noble in its intent. Usually the noble intentions are seen as misguided but
nonetheless well intended. As therapists move from relabeling to reframes
with noble intent, the complexity and level of inference increase. Therapists
are not concerned that they do not know if family members motives are truly
positive or noble in order to suggest they might be. In fact, hopeless families
often are surprised and feel more supported when therapists seem willing to
see the strength and possible nobility in them, even when it is not apparent.
13190-07_Ch06_2ndPgs.indd 102
2/8/13 11:09 AM
An example from our clinic of reframing a well-intended but misguided

motive unfolded as follows:

Son: As soon as I walked in the door, she just went off on me!
Therapist: So she let you know right off the bat that she had an issue
with you.
Son: She always has issues with me when I come home! Im
getting to the place where I dont even want to come home
any more. If it werent for my brother, I wouldnt.
Therapist: Ah, yes, your brother. Well, first of all, I want to thank you
for having that commitment to your brotheroften I dont
see that support between brothers in here. [Note that this
is an overt reaching out with positivity and support for the
identified patient son, and that alone can help with his
negative feelings at this moment.] And [to mother] I presume you know he loves his brother? [to son] Youve said this
to her before, right? But I think I might see a sad sequence
herewhere you [mother] may feel overwhelmed or unappreciated at home, or maybe even lonely, and certainly worried about your son since he got into trouble. So you look
to your son to show you support and reassurance by coming
home on time and such, but when he does come home, it
seems that he may caring more about his brother than for
you. This, of course, makes sense! You are the one who has
had to set limits, worry about keeping food on the table,
respond to the school, and so on. So you start to get noisy
[note the relabel] when he comes home, and it does get his
attention. But now it is negative attention, and he hears
more what he calls nagging or going off than what you
might be feeling underneath, which is your [moms] concern
for him and his future. And if I may, this might also include
concern about his not being as close to you as when you all
were first struggling with not having Dad around.
So, may I ask how it came about that you [to mother]
dont feel OK about asking for his support more directly?
Sometimes it starts out innocently enougha lot of mothers dont want to add burdens to their sons, so you [note the
switch from the generic mothers to you] protect them
from your own feelings of hurt and abandonment. [Note the
sense of noble intent of her nondisclosing behavior.] But
then moms get scared or feel unappreciated when their kids
come home and dont reach out to them. And thenwell, it
is sad and ironic that for many of us, it is easier to express our
pain through anger, like going off, rather than just saying,
Im lonely; Im scared. And to make matters worse, lots of
motivation phase
13190-07_Ch06_2ndPgs.indd 103
103
2/8/13 11:09 AM
young men dont get a lot of opportunities to learn how to

deal with their parents loneliness, so they dont do anything
out of fear of making things worse! [This implies a possible
noble intent in the sons behavior, thereby representing a
reframe with noble intenta reframe +.]
After training hundreds of FFT therapists nationally and internationally

over the past 35 years, we have found that the aspect of looking for the possible
underlying decency in all family members can become a model crisis point for
some new FFT therapists. Some have a difficult time inferring possible nobility
or decency in people who do bad things. It takes a leap of faith to assume
that somewhere underneath, there are hidden but positive aspects to each
person, especially when all that is apparent is very negative. Some therapists
have to work hard to learn to make that leap. Whether or not there truly is
some good under all the obvious flaws is not the issue. It is the belief that there
is some good, not the truth, that determines what we do. The therapists
who struggle most in their work with difficult families are those who believe
that these families are fundamentally negative (i.e., sick, bad) at their core
because these therapists tend to see behaviors consistent with their beliefs:
pervasive and reciprocating negativity. We view this as a form of self-fulfilling
prophecy that does not bode well for therapeutic alliance, treatment completion, or behavioral outcomes. Alternatively, FFT therapists who look for and
try to verbalize possible benign or noble intent often find it and, as a result,
can go a long way toward rapidly changing negative schemata and expectations in troubled families. Thus, reframing, especially reframing with noble
intent, represents a core philosophy as well as a specific set of techniques. It
is powerful. To support this position, our research (e.g., Robbins, Alexander,
Newell, & Turner, 1996; Robbins et al., 2000) has demonstrated that positive
outcomes are directly related to therapists use of reframing, whereas therapist
reflection of negativity, without the reframing component, is associated with
increasing negativity and dropout.
Reframes consist of a simple three-step process:
1. Identify and make clear the negative aspects of a problem behavior or pattern (the one you are going to attempt to reframe).
2. Offer a possible noble (or at least more benign) but misguided
intent or meaning.
3. Observe the family for feedback; then, on the basis of the family
members reactions (affirming or disaffirming what you have said),
refine and elaborate the reframe or apologize for misunderstanding and move on.
A common feature of reframes is that they link emotions, and often
relational needs, to the experiences and beliefs of family members, but in
13190-07_Ch06_2ndPgs.indd 104
2/8/13 11:09 AM
new ways. Remember, however, that reframes are not presented to avoid the
issue of negative behavior. It is essential that therapists, prior to presenting reframes as possible alternative explanations for behaviors or motivations, first validate the negative impact of the behavior. Reframing does not
minimize the negative impact of bad behavior; bad behavior is bad! Instead,
reframes add a focus on the possible motivation that implies that the motives
may not be completely evil or malevolent. This distinction is key to helping
interventionists respond to negative behavior but in a way that lowers defensiveness and resistance and enhances alliance.
For example, as part of the referral information, the therapist is informed
that one family member slapped another, and the therapist must first validate
the physical and emotional pain:
Clarice, you must have felt awful, physically and emotionally. Lots of people who hit dont realize that it is humiliating as well as painful [validation
of behavioral impact, which then can be followed by the reframe]. John,
when you hit Clarice, did you imagine how it would hurt her, or were
you more focused on your own feelings, like maybe feeling out of control
because she was getting the upper hand?
Note this is mostly a relabel, not a reframe and certainly not a reframe +.
In this example, the victims pain was first validated, and then the situation
was broadened to suggest motivations (or at least experiences) on Johns part
beyond simply inflicting pain.
Reframes such as this do not excuse the behavior, but they provide
more of an affiliation and alliance-based attempt to motivate change rather
than the message you are a bad person for hitting; you must stop this
behavior; when you feel anger like this you must.... The relabel allows
the therapist and family, especially the person who did the slapping, to
clarify the underlying motivational structure and develop alternative sets
of internal and external cues as a basis for change. Not all such relabels
and reframes are successful in the moment, but therapists willingness to
offer them, whether or not they are clinically rich and effective, predicts
significantly the likelihood that all family members will return to continue
the journey of change.
Occasionally, some clinicians and criminal justice workers have expressed
the concern that reframes will be taken as excuses by that subset of youthful
offenders, abusive and neglectful parents, siblings, or others identified with
such labels as sociopath. However, reframes have been developed as a key
component of the Motivation Phase, and if reframes do not serve to motivate
positive change, then they should not be used again and again. All therapists
understand that persistence alone will not help troubled families change. If
something is not working, therapists must flexibly develop alternative specific
strategies to meet Motivation Phase goals.
motivation phase
13190-07_Ch06_2ndPgs.indd 105
105
2/8/13 11:09 AM
The processes involved in change-meaning techniques often are

enhanced by therapists letting the youth and parents know weve been
there. For example, an FFT therapist can say things like the following:
I know you did those bad things not because you are evil, but because
you want so desperately to belong. I know you are scared of rejection,
and I know you may not even know that yourself. Ive sure been there
I know what it feels like to fool myself.
Or, if the clinician has not been there, he or she might say,
Ive sat in this room with too many people in the same pain you are in,
and Ive seen what finally comes out after all the rageso Im not fooled
by all your anger, even if you are still fooling yourself. How do the rest
of you [other family members] express your pain? [note the relabel of
anger as an expression of pain]...getting angry like Dad? getting
high? feeling helpless?
In the same way, an FFT therapist may say to a mom,

So he seems to think he beat the hell out of the other kid because the
other kid got in his face, and he also probably did it to prove he was bad
to his friends. So his real motive may have been to fit in with his friends,
and Im pretty sure he is terrified of rejection. What do you seethe rage,
the fear, the need to belong, or other things like the awful fact that his
father didnt seem to care at all what he felt?
These examples demonstrate that reframes are not simplistic or super

ficial. They are sometimes blunt or complex, and they deal with the ugly reality in which many of our youth and families live. Often they confuse people
more than create enlightenment. This is fine with us because the confusion is a
wonderful temporary alternative to the certainty that my kid is hopeless, my
wife is a bitch, my husband is a drunk, God is punishing me because I got
pregnant before I was marriedin fact, I hardly knew the guy! and so forth.
It could be that a true sociopath might hear reframes and use them
manipulatively, but our experience is that reframes send a message of honesty
and commitment to the youth and family, and often they can produce an
increase in alliance and in the motivation to change. And because most professionals seem to believe that true sociopaths cannot change, then those few
we see who might be true sociopaths will likely fail in FFT (and all other treatment models, it would seem) anyway. Further, when most conduct-disordered
youth are challenged with their negative behavior, it is under those circumstances that they become defensive, oppositional, and even less responsive
to change. In other words, therapists can often elicit the very behaviors that
present as antisocial. Our change-meaning and related strategies offer powerful techniques to impact that large percentage of youth and families who
appear to be unchangeable but, in fact, can and do change!
13190-07_Ch06_2ndPgs.indd 106
2/8/13 11:09 AM
In addition, by also acknowledging the negative aspects of behavior

before reframing it, the FFT therapist becomes both a change agent and
increasingly a part of the family system. In other words, the FFT therapist
does not simply verbalize such platitudes as Gee, we are all wonderful here.
Instead, he or she send the message that I know how awful you can be, but
I know there is more to it, and Im committed to finding it. Obviously, it
is imperative that therapists, when developing reframes, are careful to be
culturally (ethnically, racially, gender relatedly, sexual preference relatedly,
spiritually) sensitive and express an openness to value systems that may be
quite different than their own.
So as thoughts for the reader, consider the following: Can you believe in
the possible good in people before that good can be seen? Can you treat them
as if they might have underlying decency and dignity (i.e., can you reframe +
them), even if you are not sure and there is no proof that they do? Can you
work to create a possible decency of motive in people whom you truly dislike?
Can you consider the possibility that someone you truly believe is bad might,
in fact, be damaged instead?
Creating Themes
Themes are interventions that are intended to link the pervasive negative experiences of the past to a possibly hopeful experience of what they may
mean. Themes represent a more global perspective to the family about themselves, but they retain the same basic core of reframes in that they offer an
alternative meaning or experience of painful past relationship patterns. This
alternative meaning temporarily provides family members with a sense that
they are not defined solely by their past bad behavior but by a shared experience that emerged from misfortune, misguided attempts at positive solutions,
and sometimes merely the unfortunate events of living with fewer resources
than they needed.
Compared with reframes, then, themes are broader and more inclusive:
They link everyone together, and they can be considerably more diffuse than
reframes. Themes also can take advantage of coincidences and seemingly
unrelated events because the general links are much more like hypotheses
than explanations or interpretations. Finally, themes can offer a more hopeful
way to experience the past and to set the stage for the future.
To generate behavioral themes, therapists identify sequences of several problem family member interactions in which all of the negative elements are identified but reframed (or at least relabeled). This focus has the advantage of helping
create a family (vs. individual) focus, and because all members are subject to
reframing, the therapist can identify negative interactions and yet still come
across as seeing the possible benign intent of each member. In this way, the
therapist avoids taking sides with family members and lessens the defensiveness
motivation phase
13190-07_Ch06_2ndPgs.indd 107
107
2/8/13 11:09 AM
that typically occurs when only an individuals negative behavior is the focus.
At the same time, these types of themes are obviously fairly difficult to create
because they move the focus from one to another negative behavior on the part
of more than one person. However, as therapists are successful with the previously described change-focus techniques, the family as a whole is much more
positively responsive in ways that they would not have been earlier, when the
focus was almost exclusively on negative behaviors.
Relational themes are so called because they switch the focus to relationships rather than behaviors. Relational patterns and how they have been
experienced become the major focus. And although relational themes maintain the basic elements of reframes (i.e., acknowledge the negative, reframe
intent or meaning in more benign if not noble terms), they often seem more
like stories and even myths than specific sequences of negative behaviors.
They also tend to describe emotional states and misguided attributions,
including cognitive distortions, transference-based processes, and stereotypic
thinking, rather than reality-based awareness.
Examples of Relabels, Reframes, and Themes
The following far-from-exhaustive list of short relabels, reframes, and
themes provide examples of how FFT therapists reinterpret family relational
patterns in a new light:
77
77
77
77
77
Anger implies hurt. Almost every time we see or feel anger, it

almost always reflects an underlying hurt. Unfortunately, people tend to hide the hurt with anger, so others dont understand
the hurt, only the anger.
Anger implies loss. Anger may reflect a fear of hurt or loss of love,
control, sense of trust, sense of family, and so forth.
Defensive behavior implies emotional links. Someone (e.g., child,
parent) acts defensively when he or she lies because it is difficult for him or her to lie to the other person. That implies a
relationship and fear of losing the person by telling the truth,
which he or she may fear the person does not want to hear.
Controlling behavior can imply emotional links. Some people behave
in a controlling, apparently insensitive manner not because they
know that this will change others behavior but because they
feel that they are doing the best they can, and they never want
to send the message Im giving up on you.
Nagging implies importance. People nag (criticize, argue) because
the other person is important. Someone who nags wants the other
to be close, available, and nondestructive to the relationship, for
example. Unfortunately, people tend to forget the underlying
13190-07_Ch06_2ndPgs.indd 108
2/8/13 11:09 AM
77
77
77
positive reason for the nagging, so all the others hear is the
criticism.
Pain interferes with listening. When someone seems insensitive,
selfish, and so forth, it may reflect the fact that they are in too
much pain (or fear, or sadness) to be able to consider others. This
is particularly hard to understand when people cover their pain
with anger, selfishness, and other negative behaviors.
Fear can imply differences. Some individuals are afraid of differences because they fear that differences will lead to lack of
commitment, loss of control, and unwillingness to continue the
relationship. People are frightened by differences because they
do not trust the process of dealing with differences.
Bad behavior can imply protection. Sometimes people do bad things
(e.g., fail to support their mate, act out) to protect someone else
by taking the focus off of him or her or forcing the family to get
outside help.
Note that these simplistic examples, often offered in some form to many
families, do not focus on specific behaviors per se. Instead, they seem to reflect
more the challenges of being human, of struggling in inefficient but not meanspirited ways, and of perhaps needing help to change more than needing the
embarrassment, humiliation, oppressive control, and punishment they often
experience. It helps to understand that relational themes borrow from many
intellectual, philosophical, anthropological, and even spiritual frameworks
rather than traditional behavioral, cognitive, and even systems perspectives. For
some therapists, relational themes therefore represent a major reach both intellectually and stylistically. Those therapists can still be quite competent in FFT,
but they use other change-meaning techniques more than relational themes.
Other therapists find the ability to move away from the stark reality of
problem behaviors to be quite freeing, and they often can create experiences
in families, even in early sessions, that are quite dramatic. Relational themes
often become more like songs, poetry, and movies in that they can move
people, albeit only temporarily, into places of positive experience and hope.
The burden of hopelessness, resentment, and anger toward another family
member is huge, and sometimes through themes we can give family members
a brief sense of relief from this burden. Because we provide this relief when
the family members are all present, they can and often do have a remarkable
synergistic effect. To the FFT therapist as well as the family members, this
effect is almost palpable. Coupled with the core generic principles of matching and respectfulness, these powerful change-meaning techniques help
families move quickly to being open and responsive to techniques to change
behavior (in the short and long term), to be described later in this chapter.
motivation phase
13190-07_Ch06_2ndPgs.indd 109
109
2/8/13 11:09 AM
Sequencing Interventions in the Motivation Phase

The depth and complexity of change-meaning techniques capture the
complexity of clinical work with youth and their families. However, in presenting the sequence of interventions in the Motivation Phase, we remind
the reader that one of the simplest and most influential techniques in all
interpersonal relationships, including those that develop in psychotherapy,
is listening. Yes, listening is a skill and therapeutic technique. Knowing
when to talk, when to interrupt, and when to sit back and listen are all skills
that can be learned and refined. When attempting to positively enhance
relational issues and create a motivational context for change, seasoned
therapists recognize that it is not always necessary to generate or create their
own complex relational reframes. Instead, relational reframes and themes
are frequently provided by family members in the content or process of their
own communications, albeit in very subtle and masked ways. The skill is
being able to listen to family members and hear the positive aspects of their
communication.
Effective communicators not only ask good questions and patiently listen to the content of family members statements but also consistently attend
to feedback by observing family process and individual behaviors. Tracking
content and process over the course of a session is critical for identifying
when a family or individual is stuck. Therapists who push their own agenda
rather than checking with or tracking what appears to be the familys agenda
run the risk of increasing defensiveness and losing family members from treatment. At the very least, therapists who are not tracking the relational meaning of moment-to-moment interactions in treatment are making their own
job considerably more difficult. Therapists will find that it is much easier to
use what the family brings to the table rather than pushing their own agenda
onto the family. This does not mean that therapists follow the whims of
the family. Rather, tracking content and process requires listening for and
extracting those themes that are present in the current interactional context
that are consistent with the therapists relational goals.
How family members respond to therapist statements is the best indicator of where the therapist is at every moment in the session. If a therapist is
trying to join an individual and the individual continues to respond defensively, there is a good chance that the individual is not feeling understood or
feels that the therapist is being disingenuous. At this point, it is critical to go
back to asking open-ended questions and listening to what the individual is
saying. Once again, this listening must focus not only on the content of what
the individual is saying but also on the meanings these statements have about
relationships within the family and with the therapist. The goal of questioning is not to learn information but to create opportunities to acknowledge
13190-07_Ch06_2ndPgs.indd 110
2/8/13 11:09 AM
family members for the purpose of building alliances and setting the stage for
change-focus or change-meaning interventions.
And once again, attending to emergent processes and issues requires
that therapists are fearless in their empathy and support of family members.
When therapists see smoke, they are likely to find fire. A key aspect of training
involves teaching therapists to trust their own emotions and instincts in the
session. When they feel threatened or on the spot, it is critical to identify the
source of their discomfort. It is easy for therapists to avoid a difficult family
member, a contentious family relationship, or a hot topic. This, unfortunately,
only delays the emergence of the inevitable or, if missed too many times, leads
to premature dropout because treatment will lack immediacy and relevance to
family members. Therapists must address meaningful issues by going quickly to
the individual and relationship processes that are generating the most negativity. The first step of this process is acknowledging the negative aspects of the
communication to establish that the therapist understands, although does not
necessarily agree or disagree with, individual family members perspectives.
Once this understanding has been established, family members become more
open to change. More important, because the therapist has listened closely to
what family members have said, he or she has a better sense of how to tailor or
match reframes and themes to each family member.
Indicators of Successful Outcomes
in the Motivation Phase
The Motivation Phase is expected to be brief (two to three sessions,
sometimes within as few as 710 days) and to target very specific clinical processes or outcomes. Although the specific ways that outcomes are expressed
are unique depending on the qualities of each family, the desired outcomes
are common across just about all families. In FFT, change-focus and changemeaning techniques are used to achieve very specific observable behavioral
goals, including
77
77
77
balanced alliances with the therapist,

decreased within-family negativity and blame, and
increased hope.
Other significant markers of progress in the motivation phase are

77
77
77
77
increased family bonding,

changed and more positive attributions,
positive body language, and
a sense of familyness.
motivation phase
13190-07_Ch06_2ndPgs.indd 111
111
2/8/13 11:09 AM
When these outcomes are achieved to at least some extent, the FFT therapist
prepares to move into the Behavior Change Phase, which is designed specifically to change the referral and related problem behaviors (e.g., attitudes,
emotional reactions) and the processes that elicit and support these problems.
Please note the above phrase at least to some extent: After a mere two or
three sessions, we are not expecting that the family has achieved perfection.
This phase is about helping families move quickly to a good enough place
emotionally and attitudinally that they are willing to begin the behavior
change processes that FFT provides. So sometimes we would use the phrase
less discouraged rather than hopeful to describe a family ready to move into the
Behavior Change Phase. They need not be wildly enthusiastic but rather only
willing to give things a try without undermining the processes before they can
even begin to change behaviors.
This, of course, sounds fairly modest, but we remind the reader that
this approach differs dramatically from some others that seem to take sides
(e.g.,Were going to show you how to get control of your son or How can
you expect your daughter to stop acting out when you yourself are entertaining boyfriends and drinking at home?). We also do not make promises like
we have seen in some marketing films (Our program will teach you how to
get your child back under control. No more arguing, no more disrespect, no
more drugs...). FFT also differs from programs that offer possibly demeaning or insensitive initial stances with family members (e.g., First, lets take
off the hat and earphones or Mom, we need to turn off that TV show
were here to do family therapy). Rather, FFT therapists jump in and begin
working quickly, fearlessly, relationally, and positively.
13190-07_Ch06_2ndPgs.indd 112
2/8/13 11:09 AM
7
Relational Assessment Phase
The Relational Assessment Phase is a central and uniquely identifying

element of Functional Family Therapy (FFT). Relational assessment addresses
two family relationship domains: (a) the degree of connection between family members and (b) the hierarchical pattern involved in those connections.
Relational assessment identifies how to approach specific changes in this particular family to encounter the least resistance and create the most lasting
effects. Relational assessment provides a framework that addresses not only
the specific problem behaviors for which youth and families were referred
but also the unique abilities and styles of the family members with respect to
each other.
In technical or behavioral terms, relational assessment can be described
as identification of patterns of interpersonal antecedents and consequences
of behavioral patterns relevant to dysfunctional behavior. Why are patterns
identified? The extensive and well-researched literature on risk and protective
DOI: 10.1037/14139-008
113
13190-08_Ch07_2ndPgs.indd 113
2/8/13 11:17 AM
factors, as well as the consistency of dysfunctional behaviors that get youth

and families into treatment, are inevitably reflected in patterns rather than
isolated events. Even youth who present as callousunemotional after a
single major event, such as an arrest, are rarely referred to therapy because
of that single event; instead, they inevitably have developed patterns of
dysfunctional behaviors that have brought them to the attention of at
least one important person (family member, teacher, police), and usually
numerous others.
Note that as we highlight the importance of relational assessment to
prepare for behavior change, we do not de-emphasize the other factors wellknown to influence behavior, such as genetics, severe trauma, and temporary or longer-term effects of illicit substances. However, by the time we see
youth and their parent figures, it often is difficult to separate cause and effect
because rarely do these behavioral patterns emerge overnight. Sometimes
one or two specific events can be identified that might appear to have started
the patterns for which youth and families are referred, but additional contributing factors have been involved.
A review of risk and protective factor lists (e.g., Hawkins, Catalano, &
Associates, 1992) demonstrates the multiple dimensions on which contributors to adolescent problems are distributed. Further, even when it appears
that a specific major event has had considerable impact (e.g., a parent becomes
unemployed, an already delinquent teenagers family moves next door), the
event itself cannot be undone directly. Neglect and trauma already have
occurred, maladaptive coping patterns already are learned, and substance
abuserelated cognitions already are in place. Thus, the issue becomes not
one of narrowing our focus down to a single or a few etiological factors and
removing them but instead one of accepting who and what people are when
they are referred to us but helping them develop more positive alternative coping patterns that they can sustain as they face current and future
challenges.
Pattersons description of the reciprocity cycle in the development of
child behavior problems (e.g., Patterson & Reid, 1970) captures the essence
of what FFT therapists address in most, if not all, dysfunctional families. The
child and parent behaviors that constitute the reciprocity cycle represent
interdependent and predictable patterns, and the therapists job is to disrupt
the patterns and replace them with new, acceptable, and productive patterns.
Relational functions represent a shorthand method of organizing these patterns, which often are expressed through a variety of specific behaviors across
contexts. In this chapter, we provide an overview of the goals, tasks, and outcomes of the Relational Assessment Phase of FFT. Although the Relational
Assessment Phase overlaps with the Motivation Phase in real time, we highlight this process as a separate phase because the activities and skills required
13190-08_Ch07_2ndPgs.indd 114
2/8/13 11:17 AM
in relational assessment are distinctly different than those required during

the Motivation Phase. Moreover, the activities of the Relational Assessment
Phase must be completed prior to the initiation of the Behavior Change
Phase (see Chapter 8) because the accurate assessment of relational functions
is essential for effective treatment planning.
Goals and Tasks of the Relational
Assessment Phase
The goal of the Relational Assessment Phase is to identify the patterns
of connectedness and hierarchy in the family as these patterns relate to the
problems family members experience. Beginning with the initial contacts
with family members, therapists start to formulate hypotheses about these
patterns and the individual skills and behaviors that are linked to them.
Relational assessment can begin even before initial face-to-face contact with
the family, but it usually is minimal at first because other systems (e.g., referral sources, school systems, mental health and juvenile justice systems, individual therapists, psychiatrists) rarely conceptualize youth and families in the
FFT relational framework. Once we begin to see a family, however, relational
assessment becomes an overriding context or frame within which therapists
think about and plan specific intervention strategies with specific behavioral
targets. In fact, even as therapists formulate and implement change-focus
and change-meaning interventions during the Motivation Phase, they also
are learning valuable information about the interpersonal payoffs of problem
behaviors for individuals in the family. The therapists ability to synthesize
patterns from observations of family members and their descriptions of relational sequences depends on his or her perceptiveness about the relational
meaning of these observations, and these patterns represent critical components of accurately assessing relational functions.
Relational Assessment, FFT Philosophy,
and FFT Phases of Change
To borrow an old existential phrase, we characterize FFT as working to
understand a familys way of being-in-the-world (Heidegger, 1927/1962) to
join with them in a partnership for change. Therapists work with and not
on them and, in doing so, create a sense of respectfulness that often they
do not otherwise experience from schools, judges, neighbors, and sometimes
even churches when they are referred for problem behaviors. The philosophies of matching and individualizing change mean that FFT therapists do
not use this information to try to make all youth become close to their parents,
relational assessment phase
13190-08_Ch07_2ndPgs.indd 115
115
2/8/13 11:17 AM
nor do they push to help all youth become independent from their parents.
FFT therapists do not intend to make all mothers close to their kids or to
make them all become less involved with their kids. FFT therapists do not
intend to make fathers more like a friend to their kids or less like a friend
and more like a parent. FFT therapists do not intend to create adult relationships (e.g., marriage, partnership) that are all symmetrical or all one-up or
one-down. In sum, FFT therapists do not become involved in the lives of dysfunctional families to make them into something they are not or something
someone else says they have to be.
Instead, what FFT does is to help dysfunctional families become functional and better versions of themselves: Families with delinquent youth
become families with nondelinquent youth; families with abusive parents
become nonabusive families; and families with depressed and overwhelmed
parents become families with parents who are happier, are coping better, and
have a sense of hope and self-efficacy. FFT therapists accomplish these goals
by working with the relational configurations the families have already have
developed, but they then provide families with alternative, more adaptive
ways to express these configurations.
As human beings, we learn from experience what sorts of interpersonal
and family-based behavioral patterns and strategies work to attain certain
specific motivated goals in certain conditions. The process begins in early
childhood. For example, a baby may learn that throwing a tantrum makes
his or her mother pay attention to him or her. Then, as children move into
the outside world, they bring with them well-rehearsed strategies that may
or may not continue to work in these new contexts (Reid, Patterson, &
Snyder, 2002). It is during these times that, in retrospect, families can begin
to see relational patterns both within and outside of the family that increasingly emerge as important predictors of adaptive versus maladaptive behavior patterns in adolescence. In turn, as peer influences become increasingly
salient during preadolescence, adolescence, and youth, young individuals
learn even more strategies for attaining motivated goals. Like the strategies
learned as a baby, the strategies learned as a child may be prosocial or more
problematic. When the behavioral strategies are problematic, the families
experience increasing behavior problems, which get them into FFT or a multitude of other interventions. Thus, by the time an FFT therapist receives a
referral for dysfunctional behavior patterns, the relational functions the patterns reflect in important relationships usually are well established and easy
to recognize. As a result, the therapist looks for stable patterns, first assessing
the relational functions on the basis of inferences from the relational behavior patterns within the family and then repeating the assessment process for
relationships and problem behavior patterns outside the family, especially
with peers.
13190-08_Ch07_2ndPgs.indd 116
2/8/13 11:17 AM
Relational Functions as the Linchpin

for Behavior Change
In developing strategies for specific behavior changes, the central question thus becomes, How do FFT therapists conceptualize goals and interventions for changing intrafamily, and then extrafamily, behaviors to produce
positive functioning? FFT therapists first determine the relational functions
reflected in the problem behavior. Then they develop positive alternatives
(e.g., behavioral, conceptual, physiological) to help each family member
attain his or her relational functional needs. For example, if a person is motivated to achieve comfort and stress reduction but does it by ingesting drugs,
having unprotected sex, participating in gang activities, or going out on a
date and leaving young children alone, FFT therapists do not attempt to
change the relational function (comfort and stress reduction) itself, but they
do change the cognitive, physiological, emotional, and behavioral strategies
in which the youth or parent engages to meet that relational function.
We also recognize that biological-level interventions can produce
change, although in FFT, that option is seen as only one of various possible
strategies that might be applied to child and youth dysfunction. If it seems
that a child acts out to get attention, the FFT therapist does not work to
eliminate that persons need for attention. Instead, the therapist changes
the means though which this attention is elicited. This, of course, usually
requires dealing with the rest of the systems involved with the youth, because
comfort or attention may be available only through maladaptive behavioral
patterns. For example, stressed and busy parents often cannot find a way to
respond constructively to youth and children until their maladaptive behaviors become quite noisy. The parents then end up reinforcing maladaptive
as opposed to prosocial behavior on the part of the youth as a stimulus for
attention. Or parents who themselves have many challenges (e.g., physical,
emotional, financial) at the time of referral may simply not have the resources
to respond adaptively to the youths needs. As a result, in FFT, the therapists
support and guidance for change is focused not only on the referred youth but
also on many components of the systems that surround the youth. Without
change in those systems, addressed mostly in the FFT Generalization Phase,
most youth cannot maintain change on their own.
But therapists begin first with the family. FFT therapists do not prioritize
emancipation unless and until it is very clear that positive change cannot
otherwise occur, and we find this to be the case surprisingly rarely. Stated
bluntly, FFT posits that often youths and families unsuccessful responses to
previous change attempts may be less a function of the families failure and
more a function of the change programs to which they have been exposed
(see Elliott & Mihalic, 2004).
13190-08_Ch07_2ndPgs.indd 117
117
2/8/13 11:17 AM
To note another example, if at the time of referral to FFT, a parent

attempts to gain control via abusive strategies, FFT therapists do not attempt
to change a parents relational function (or need) for hierarchy and control; instead, they change the means through which the parent achieves the
control, replacing negative behaviors with positive and prosocial parenting
behaviors. Again, however, with adolescent referral populations, this usually
cannot be accomplished without engagement and motivation on the part of
both the youth and the parent.
We have found that the generational patterns of relational functions
that have developed within families reflect the fact that often the parents
themselves are poorly suited to help teach, model, or reinforce positive and
adaptive relational patterns for their kids. Often the parents also were raised
with restricted positive leaning opportunities and, at the same time, they also
are struggling with new challenges of their own. These challenges can include
poverty, unemployment, racism, and cultural differences, as well as their own
mental health, spiritual, physical, relational, and family-of-origin challenges.
By working directly and respectfully with all family members, FFT therapists
can address all of these layers of intersecting variables and processes and, in
fact, help family members help themselves and each other to change in a
positive, synergistic manner. Understanding and accepting all family members
where they are with respect to relational functions, and doing so respectfully,
provides all family members with a hopeful starting place for change. Such
understanding and acceptance lead therapists to help family members experience that they can change on the basis of who they are rather than who they
should be.
But why relational functions rather than individuals specific problem
behaviors as the primary focus? Common sense tells us if we fix an individuals
problem behavior, we fix his or her relationship problems. However, consistent with the theories we discussed earlier, including systems theory and social
learning perspectives on behavior, FFT addresses relationships as the portal
through which one most effectively produces change. Considerable research
literature comparing individual as opposed to family and systemic therapy outcomes for high-risk youth support the wisdom of adopting a relational versus
individual perspective and, more specifically, the comparative efficacy of FFT.
At the same time, the shift to a primary relationship focus required a
change in how therapeutic strategies and techniques are organized. For FFT,
problem behavioral patterns offer a window into the nexus of change, but
according to FFT, they are the symptom or expression of a more fundamental
causal problemthat is, relational functioning and the behaviors that reflect
problems in that functioning. To develop strategies for improving relationship functioning, FFT as a first step follows a reliable and clinically applicable
system for assessing these functions.
13190-08_Ch07_2ndPgs.indd 118
2/8/13 11:17 AM
Assessment of Relational Functions

A function is the action for which a person or thing is specially fitted or
used or for which a thing exists (Function, 2012). Determining the function of a behavior is no trivial matter. Maslow (1943) developed a system for
conceptualizing and organizing the functions of human behavior that continues to represent an enduring framework. However, when we begin discussing
needs or the functions of behavior regarding referred families and ask
Why does he or she do that? of mental health professionals, drug treatment
resources, and juvenile justice systems, we hear the notion of need used in
remarkable and diverse ways. People describe themselves, clients, and each
other with descriptors such as I [or he, or she, etc.] need a drink [or sex, or
to get away for a while, or a better grade on this test, or a parent who loves
me, or some excitement, or some peace and quiet, or a smoke, or to go to the
bathroom, or more emotional support, or new clothes, or a kick in the butt].
And, of course, the list goes on. In clinical treatment contexts, we often hear
such aspects of human behavior discussed in more technical-sounding terms
that emphasize that human beings can and do seek myriad representational
goals, reinforcers, and behavioral outcomes.
Given the complexity of problem situations that youth and families
present in treatment, in the early stages of FFT development, we adopted a
conceptual framework for organizing the needs and functions of behaviors.
At one level, we see all of the seemingly infinite tangible and intangible specifics noted above. Beyond those, we can add more: to get high, to be with
friends, to get back at my parents. In turn, these can be nicely organized into
conceptual systems such as the Maslow (1943) hierarchy.
Then, to facilitate a logical and manageable framework within which
myriad change agents can work with myriad families, FFT further reduces the
framework into a superordinate relationally based system. That system identifies the various patterns that express what we call relational functions. They
represent the interpersonal expressions of myriad specific outcomes in two
major relational categories: relational connection and relational hierarchy.
These two categories are not unique to FFT. For example, Lorna
Benjamins (1993) Structural Analysis of Social Behavior (SASB) Circumplex
system assesses interpersonal behavior, traits, and motives along two orthogonal
axes: a vertical axis (of status, dominance, power, or control) and a horizontal axis (of solidarity, friendliness, warmth, or love). The SASB Circumplex
system is, in turn, based on an older framework, the Leary Circumplex or
Leary Circle (Leary, 1957). Like these and similar approaches, FFT considers that the complexity, diversity, and richness of human functioning and
relationships can be translated into two relationship domains: relational
interdependency and connection (push away or pull in) and hierarchy
13190-08_Ch07_2ndPgs.indd 119
119
2/8/13 11:17 AM
(one-up, symmetrical, or one-down). The remainder of this chapter elaborates

on these two domains.
Relational Connection
The first and most salient FFT relational domain pertains to the nature
and degree of interpersonal connectivity seemingly involved when a person
expresses a stable behavior pattern that directly or indirectly impacts another
person. Interpersonal connection can involve degrees of being close, or highly
interconnected, and being distant, or autonomous. However, across time and
specific relationships, closeness and distance do not represent a simple continuum. Sometimes both are present simultaneously, as all clinicians have
experienced with so-called borderline clients and in many situations of a high
degree of ambivalence in the connection between a chaotically emancipating
youth and his or her parent or parents. With adolescents in particular, the
connection, even in normal families, can range from highly close to a parent
to highly autonomous, or sometimes a blend (often described as mixed messages). When roughly equal amounts of closeness and autonomy are present,
in FFT, the relational connection is described as midpointing. Such a connection can be comforting, as when the adolescent can work independently at
school and, perhaps after school, can participate without the parent in extracurricular activities (e.g., music, sports) but also can connect strongly with the
parent when the youth is at home as expected or desired by the parent.
However, as will be explained below, very problematic vacillations
also can occur in midpointing situations. In fact, as we continue to elaborate below, all relationship situations can represent positive expressions of
contact/closeness, midpointing, or distance/autonomy, or they can represent
very problematic expressions of those relational configurations. In this way,
FFTs concept of midpointing in relational functions is quite similar to Bems
(1981) notions regarding androgyny in gender stereotyping. Androgyny is
not simply a midpoint on a unitary dimension ranging from highly feminine
to highly masculine. Instead, androgyny can represent a complex blend of
both strong feminine and strong masculine elements. Figure 7.1 reflects how
closeness, midpointing, and distance can range from low to high amounts in
any given relationship.
Of course, no one persons behavior in a given dyad is consistent at all
times, but FFT focuses on two important aspects of relational functioning
in referred families. First, what is the central tendency (i.e., the rule rather
than the exception; the most likely pattern) of behavior over time? Second,
in particular, what seems to be the pattern that is most often associated with
acting out or the patterns that represent problems within the family or larger
environment?
13190-08_Ch07_2ndPgs.indd 120
2/8/13 11:17 AM
High
Degree of Autonomy
Autonomy
Midpointing
Low
Closeness
Low
High
Degree of Closeness
Figure 7.1. Relational functions: Interpersonal relatedness.
In FFT, therapists attend primarily to the people and connections that

seem most directly relevant to the behavior problems that bring youth and
families into treatment. This system helps therapists separate distal influences
from proximal. For example, a youth who was abandoned years ago may still
experience trauma from that abandonment. However, in FFT, we focus on
the current manner in which that youth currently approaches or connects
withor avoids or disconnects fromcaregivers and others. Of course, how
the youth behaves in the present may be strongly influenced, if not determined, by that distal abandonment, but the goal in treatment is to help that
youth and his or her environment (especially family) develop adaptive, nonproblem ways in the present to meet his or her needs in the current context
with the current caregiver with whom he or she lives.
In FFT, we simplify these patterns into three components: contact/
closeness, midpointing, and distance/autonomy. The definitional anchors for
each of these components do not represent fixed and invariant points; they
are instead the seeming central tendency, default mode, or average of the
behavioral patterns that best characterizes the ongoing relationship. Imagine,
if you will, a couple in an ongoing relationship: They are not always close
or always distant or always seemingly a mixture of both. However, all of us
know what we mean when we say this couple seems close as opposed to they
have a lot of autonomy in their relationship or they seem to be hard to pin
downsometimes they seem real close and other times quite autonomous
from each other; it is like they are both.
13190-08_Ch07_2ndPgs.indd 121
121
2/8/13 11:17 AM
Why and how do people develop these patterns over time? Sometimes
therapists know or can find out; other times, we never know. As noted several
times already, individuals are not always consciously aware of what motivates
their behavior. Often, in fact, what they seem to understand about why they
behave the way they do is at odds with the understanding of other observers.
FFT, for better or worse, has developed in a manner that can and does allow
these various etiological theories and perspectives to inform how we think
about the here and now.
At the same time, this perspective does not require us to take a strong
stance in favor or disfavor of any particular etiological model or a specific
technique. This, in turn, helps with our flexibility and accommodation to an
extremely wide range of referral youth and contexts. For example, we may
never know why a stepfather seems to be so closed off emotionally from his
wife, the mother of the referred youth. He may have had early experiences
that set him up to fear emotional closeness with a woman, or his first wife may
have betrayed him and used his emotional closeness as a reason for doing so,
or he may be depressed. He may even be simply living up to self-expectations
based on his interpretations of his cultures demands and expectations of men.
What we do know is that his pattern of distance, autonomy, and shutting
down is problematic for his wife, so we work toward a new interpersonal style
with his wife that she experiences as more open and available, yet one in which
he still feels that his vulnerability (expressed as autonomy) is protected and
even respected. Notice that in this example, we did not require that the wife
give up on her need to be closer to her husband. However, we work on ways
in which she can ask for or elicit more behaviors that she experiences as close
but without him experiencing them as overwhelming or dangerous. These
examples should remind readers that FFT requires creativity and flexibility.
In turn, this flexibility results from one very simple yet profound aspect
of FFTs intervention philosophy. That philosophy can be summarized as the
respectful acceptance of the diversity that all family members bring us in
terms of relational functions. Again, as noted above, to help youth and their
families, we do not require them to represent one particular kind of relational
function. We instead believe that youth can be adaptive and happy whether
their relational need with a parent is for more contact, closeness, and inter
dependence than is the norm for their age or culture; or for more autonomy
and independence than is the norm; or for a relational function that represents a balanced expression of contact and autonomy.
All three of those relational states can be adaptive, and all three can be
maladaptive. The problem is not what the relational function is, but how it
is expressed and met. A parent who is emotionally and physically close and
heavily focused on his or her adolescent youth can represent the icon of positive parenting (e.g., Parents: It is 10 p.m.; do you know where your child is?
13190-08_Ch07_2ndPgs.indd 122
2/8/13 11:17 AM
Parents: Be willing to do the tough thing. Know your adolescent, know his
friends, know where she isask questions.). However, another parent with
a similar relational function of contact, closeness, and interdependency, if she
expresses it in other ways, faces being identified as enmeshed, overbearing,
overcontrolling, even codependent. So for FFT, it is not the degree of attachment but rather the means through which the parent maintains the relational
function and how it fits with the relational function of the youth.
To continue with a very different example, consider the parent who
generally reflects a relational pattern of more autonomy than closeness with
the child. This parent can face the label of being uninvolved or uninterested
or can be praised for being able to raise the type of adolescent to which he
or she can grant a fair amount of autonomy. A parent can monitor a youths
behavior directly and with an emotional overtone (contact/closeness), or the
parent can monitor just as effectively but from a less directly close style via
notes, text messages, and written rules and checklists. Both involve monitoring activity, but one involves direct contact (high connectivity) with the
possibility of emotional expression, whereas the other represents monitoring
from a safer (for some youth and parents) distance, which reflects greater
autonomy. Each of these patterns, in turn, matches different teenagers well
or poorly depending on the youths own interpersonal functions.
Thus, the relational functional patterns of youth must also be considered because they codefine the transaction between them and their parents.
Some youth are quite attached behaviorally to a parents, and the attachment is
expressed in positive terms. Others are quite attached but do so in ways that are
labeled dependent, unwilling to emancipate, and so forth. At the other extreme,
some of the most troubling teenagers are autonomous and even dangerously
so (e.g., spend most of their time with gangs and deviant peers); others are
autonomous but in very adaptive and effective ways (e.g., spending lots of time
studying on their own, engaging in sports or a job after school, spending lots of
time with prosocial friends without the need for supervision). Again, it is not
the degree of connection or autonomy but rather how parents and youth manage to attain, grant, and manage the autonomy. Given this, FFT therapists are
particularly sensitive to matching specific behavior change techniques within
the family (see Chapter 8, this volume) and in situations involving relationships outside the family (see Chapter 9, this volume) to the relational functions
that are determined during this Relational Assessment Phase.
Finally, often the intensity of a relational function is wrongly confused
with the intensity of an emotion. Sometimes extreme situations of, for example, distance/autonomy are paralleled by very high emotional intensity. An
abused woman fleeing from her abuser with her child in her arms is doing
everything possible to create distance, often permanently, from the abuse.
These attempts also are coupled with strong emotions of fear, avoidance,
13190-08_Ch07_2ndPgs.indd 123
123
2/8/13 11:17 AM
and preservation. In other circumstances, extreme distance can be created

by indifference and simply ignoring another, particularly when the other has
strong connection needs. FFT looks at the pattern of interactive behaviors
rather than the intensity of one persons expressed emotion to determine
relational functions.
Relational Hierarchy
Relational hierarchy reflects the pattern of relative influence parent and
youth have over each other in terms of controlling the others behavior. In
FFT, therapists assess hierarchy for each of the relevant dyadic relationships
in the family. As shown in Figure 7.2, each relationship may be characterized
by its central pattern of influence in which a youth or parent is one-up or
one-down or the relationship is more symmetrical.
With adolescents who are referred for disruptive behavior problems, it
is common to use such phrases as out of control. However, FFT examines
more than the behavior patterns of one individual. Instead, we examine the
relative balance of control and power rather than simply isolating our focus
on whether the parent can control the youth. When therapists broaden their
focus to look at the relative balance of power, it is not at all uncommon for
them to find that a youth is able to exert less or more control over a parents
behavior than vice versa. Bluntly, sometimes the parent is as out of control
as the referred youth. Interventions that fail to examine the relative balance
of the interpersonal control in these relationships often fail repeatedly if all
therapists attempt to do is to increase the control the parent has over the
youth. Dramatic but not rare examples of the importance of understanding
the balance of control become apparent when change agents realize that the
youth has no more ability to get the parent to stop drinking (or belittling, or
hitting, or dating that loser) than the parent has to get the youth to stop
unwanted behaviors.
It has become increasingly popular for change programs involving dysfunctional youth to focus on overt control, via power and hierarchy, of their
behavior. Extreme examples are represented by boot camps and curriculumbased interventions characterized in such terms as getting parents back in
charge through limits and consequences. FFT therapists agree that parental
influence on (and, when necessary, control of) youth behaviors is critical to
adaptive functioning; in fact, it is critical for youth to experience that negative behaviors lead to negative consequences. However, we disagree that the
bases of influence and control should be primarily power and hierarchical in
nature or focused primarily on acting-out youth.
As an alternative, FFT therapists believe it is critical and often much
easier for all when parents can exert control through relational connection
13190-08_Ch07_2ndPgs.indd 124
2/8/13 11:17 AM
Me (person
doing the
behavior)
You (person
receiving
the behavior)
One-up behavior
You (person
receiving
the behavior)
Me (person
doing the
behavior)
One-down behavior
You (person
receiving
the behavior)
Me (person
doing the
behavior)
Symmetrical behavior
Figure 7.2. Relational functions: Hierarchy.
13190-08_Ch07_2ndPgs.indd 125
125
2/8/13 11:17 AM
and the quality of the relationship. FFT therapists work hard to create processes in which youth are influenced by parents because they love the parents
and want to please them, as opposed to being influenced or controlled primarily because negative behavior will lead to negative consequences. We want
youth to want to please their parents, and we want parents to want to provide
guidance through caring, not just through a need to control the youth.
For example, increasing parental monitoring of peers is widely recognized as an important risk and protective factor for youth externalizing
behaviors and therefore is often a target of change programs. However, many
programs offer a linear strategy for impacting parental monitoring by teaching or training parents to implement monitoring skills. This strategy may be
effective in a parentyouth relationship in which the parent has relatively
more relational influence or power than the youth but may not be particularly
effective when the youth has more relational influence than the parent. In
the latter configuration, a more effective strategy may be to increase parental
nurturance and warmth to create a relational context in which the more
powerful youth is willing to disclose his or her activities to the parent. As is
evident in this example, increasing parental monitoring is an important goal;
however, the means through which this is achieved must take into account
the assessment of relational hierarchy in each relational dyad in the family.
That is, interventions are delivered in a way that matches the relational
configurations.
Simple examples of recurrent hierarchical patterns are seen often in
adultadult (as well as parentyouth) interactions with respect to problem
solving. Imagine a couple in which, most of the time, the man asks the woman
for her opinion of what they should do with respect to child rearing and then
follows the womans advice most of the time. That would represent, at least
with respect to child rearing, a female one-up hierarchical pattern. In contrast, there are also situations in which a man not only rarely asks the woman
for her opinion but usually dictates what he thinks they should do as a couple.
This represents a male one-up pattern. Some couples, over time, are characterized by more give-and-take discussion, and if the outcomes of these discussions are tracked, it seems that sometimes the womans opinion represents
the path they follow, and other times it is the mans. This is a symmetrical
relationship pattern. Note that gender is not the issue here; we could just as
easily use malemale couples or femalefemale couples. Naturally, in family
therapy for parentchild relationships, we use exactly the same framework.
How Do You Know?
How does a therapist obtain and trust sufficient information to determine relational functions? Relatedly, how do we know what the antecedents
13190-08_Ch07_2ndPgs.indd 126
2/8/13 11:17 AM
and consequences are of youths and family members behaviors? In the face
of denial, distortion, fear of disclosing, and the like, all of which are part and
parcel of many of our high-risk referrals, the therapist must rely on what gets
these youth and families into treatment in the first place: patterns. As family
members begin to relate their own, often conflicting, perspectives on past
behaviors and the attributions they believe explain each others motives,
therapists begin to listen for and ask questions about patterns. As they do
so, therapists are careful to not ask potentially inflammatory questions.
Instead, they ask strength-based questions and make inferences that potentially capture relevant patterns. These questions and inferences are organized
around an apparently simple question: In recurrent problem-related patterns,
what happens when the dust settles? That is, before a behavior problem incident, are these family members close together but afterward are they further
apart? Or were they relatively more characteristically independent, but when
problem patterns occur, are they, at least temporarily, closer together?
Many working parents understand this process all too well. As they
increase their attention to work issues, the children often begin acting out,
which functions to elicit (demand) more attention. In contrast, highly attentive parents with lots of time to devote to their adolescent children begin to
experience various forms of walling offthat is, increased autonomyfrom
their children. Complicating this pushpull process between a youth and
parent is the fact that when more than one parent figure is involved, often
the relationship is different between the youth and each of the parents. For
example, arguments with a stepfather put the mother in the middle, serving simultaneously to push the stepfather away (a function of distance, not
unexpected according to the research literature on blended families) and to
keep the mother closer as she attempts to bridge the two.
Further complicating the inferences therapists must make is the fact that
most recurrent problems, with their chicken and egg quality, often require a
time frame beyond a particular problem sequence. A delinquent son who
repeatedly comes home late may experience a seemingly distancing sequence
with a tired and stressed parent. Loud arguing, which leads quickly to cursing
and the youth storming into his room, would appear to be best described as a
distancing maneuver (function) for both teen and parent. However, if, after
things settle down, the parent typically comes to the youths room and apologizes for the cursing, we must wonder if the function of the problem might be
to elicit more closeness from the parent.
To answer this question, the nonproblem aspects of their relationship
must also be examined. If this tired and stressed mother typically responds very
little to the youth when problems are not occurring, then it would appear that
the function of the curfew violation and the arguments is to elicit attention
that otherwise might not be present. In contrast, if the parent is typically very
13190-08_Ch07_2ndPgs.indd 127
127
2/8/13 11:17 AM
attentive and pays a lot of attention to the youth when curfew isnt broken,
it suggests that the function of the curfew violation and arguing could well be
to produce more autonomy for the youth, autonomy that, in fact, is seen as
developmentally appropriate. Again, it is not the function (more closeness or
more distance) that is the problem, it is the manner in which this parentchild
dyad has learned to deal with their contact and autonomy needs.
As noted many times already, FFT does not force one or another family
member to submit their relational needs to those of other family members.
Instead, therapists work to develop new behavior patterns that are consistent
with the needs of all family members. Parents can be helped to develop systems in which they still feel in control and close to their children when the
youth are seeking autonomy. Coincidentally, this is currently easier than it
was in previous eras when texting (for example) was not available. Youth can
literally send a real-time picture of where they are to their parents and text
briefly what they are doing and yet feel more independent than if they had
to be physically at home. Further, such technology does not place as much
pressure on trust, which also is challenged more often in adolescence.
Conversely, a parent invested in work or church, when dealing with
a youth who is still fairly dependent (i.e., relational function of closeness),
can call, text, and support others (e.g., friends) who can and will be with the
youth to avoid feelings of loneliness, for example. Strategies such as these
are described in much greater detail in Chapter 8 (on behavior change). At
this point, the take-home message is that dysfunctional patterns, with their
typical interpersonal payoffs, give therapists a window into the relational
motivations of the participants. As this window is emerging in therapeutic
discussions, therapists are simultaneously motivating the family members to
begin the change process.
Finally, FFT therapists are prepared for unexpected twists. Families are
complex. Therapists can produce much more reliable, higher quality outcomes
when armed with an assessment framework as a guide. Moreover, as therapists practice skills and the FFT way of thinking about families, they become
more efficient and better able to handle all of the unexpected twists and turns
with which complex clinical situations challenge us. As readers will see in
Chapter 12, this is one of the reasons we urge clinicians undertaking FFT to
work, or at least meet regularly, in mutually supportive supervision groups. In
this way, therapists expertise can include a much wider range of assessment
and treatment challenges (i.e., learning opportunities) than isolated therapists
can achieve.
13190-08_Ch07_2ndPgs.indd 128
2/8/13 11:17 AM
8
The overarching goal of Functional Family Therapy (FFT) is to change

maladaptive behaviors. As noted previously, successful behavior change
depends on families being motivated and ready for change and therapists
having a clear understanding of relational functions in the family. This
preparation paves the way for behavior change strategies to be implemented
in ways that are consistent with family relational functions. Although the
motivational readiness and the positive trajectory initiated in earlier FFT
phases are necessary prerequisites to long-term change, the Behavior Change
Phase focuses explicitly on reducing or eliminating problem behaviors and
conflicted or avoidant interactions, preventing maladaptive patterns from
reappearing, and building more positive, nurturing relationships that can be
sustained long term.
The early part of this chapter addresses the goals, process, and general
philosophy of the Behavioral Change Phase, followed by a review of the
DOI: 10.1037/14139-009
129
13190-09-Ch08_2ndPgs.indd 129
2/8/13 11:16 aM
learning theories underlying many of the behavioral interventions used in

FFT. The later sections provide brief descriptions of the strategies and techniques commonly used in behavior change. Specific topics include increasing
positive family activities, youthing skills, parent training, communication
training, problem-solving skills, and use of technical aids to foster change.
Additional techniques and frameworks that can be integrated into behavior
change to tailor the approach to the particular needs of individual families
are also discussed.
Behavior Change Goals
The primary aim of the Behavior Change Phase is to effect change in
the familys problem behaviors and the risk and protective factors associated
with these problems. The presenting problems represent obvious targets of
change, but the maladaptive behaviors that give rise to those problems and
the responses to the behaviors that serve to encourage and sustain them are
also important targets. Change efforts may focus on overt behaviors, attributions, thoughts, feelings, and even contextual behaviors such as retreating to
ones room after school or work. The aim is to foster improvements in functioning in domains tailored to the youths and familys needs.
Matching Change Plans to the Family
The unique emphasis of FFT is on the application of techniques in the
context of the assessment of functional outcomes in the family. Therapists
develop individualized change plans that fit or match the families values,
relational functions, and abilities and that increase competence in adaptive positive behaviors. Intervention attempts can lead to rapid change
or resistance to change, depending on how well the intervention strategy
has been fitted to each family members interpersonal function with each
other family member. Even when the behavior change strategy is technically correct and well developed, resistance will arise if the intervention
implemented is inconsistent with one or more of the family members interpersonal functions. For example, a youth who goes out with friends night
after night and has increasingly frequent clashes with local police may
achieve considerable distance from his parents while at the same time creating a context for his fathers function of drawing closer with the youths
mother. That is, the sons delinquent behavior allows the couple to draw
closer, discussing their concerns and attempting to problem solve how best
to help their son. Attempts to move the son into more interdependent and
13190-09-Ch08_2ndPgs.indd 130
2/8/13 11:16 aM
intense interactions with his parents might thus be incompatible with the
familys relational functions, and resistance to behavior change strategies
would be expected.
Thus, although the targets of a change plan involve the specific problem
behaviors and risk and protective factors that need to be addressed in a particular family, the way in which those changes are made is uniquely crafted
to fit the relational functioning of individual families. The goal of our behavioral interventions is not to change the relational functions of behaviors but
instead to change the maladaptive manifestation of these functions. To the
extent that relational functions represent preferences among family members
for how they interact with one another, making intervention techniques fit
the family relational system allows the therapist to develop change plans that
family members are more likely to embrace. The manner in which the therapist addresses communication problems in families, for example, could range
from techniques that require nightly family meetings (contact/closeness),
occasional as-needed checkups between family members (midpointing), or
greater reliance on written notes, texting, and voice mail to convey messages
(distance/autonomy).
Transitioning to Behavior Change:
Cycling Back to Motivation
Therapists know that the family is ready to move to the Behavior
Change Phase when they hear expressions of increased hope in the family and negativity and blame have decreased. Family members often display more positive body language (e.g., open body position, increased eye
contact), increased expressions of positive family connectedness, and more
positive attributions (though often not well formulated or certain) regarding
one anothers behaviors. When these indicators of change readiness appear
and you have at least tentative ideas about the relational functions of each
family member with every other family member, you are ready to move into
behavior change.
The transition to behavior change and return to motivation can be a process that is repeated more than once. When initial behavior change attempts
go awry, several sources for the problem should be considered. The first possibility is that the therapist may not have been sufficiently clear, directive,
or informative for family members to be able to carry out the change plan. A
second possibility is that the familys relational functions have not been met
by the change plan. A third consideration is whether the therapist needs to
cycle back to the Motivation Phase to reduce remaining negativity in the
family and further develop treatment readiness.
behavior change phase
13190-09-Ch08_2ndPgs.indd 131
131
2/8/13 11:16 aM
However, although this cycling process may be necessary, it is usually

very brief and may be accomplished simply by reviewing the reframes or
themes developed during the earlier phase, pointing out how the difficulties
with the change attempts are related to the familys old patterns of interactions, and refreshing the familys experience of hopefulness and readiness for
a new start that led to the move into behavior change in the first place.
Therapist Skills and Behaviors
During the Behavior Change Phase, the therapist is much more structured, more direct, and in some ways more hierarchical than during previous
phases. Throughout the Behavior Change Phase, interactions are structured,
and the therapist teaches, models, coaches, directs role-play experiences
through which family members rehearse new behaviors, provides technical aids, and gives practice exercises as homework to help families continue
to improve their skills between sessions. Behavior change sessions can be
quite programmatic and may involve the use of handouts and a whiteboard
to facilitate learning. Conversely, therapists can convey the content of the
various components of the change plan casually and conversationally. In
part, the use of behavior change strategies is determined by the therapists
own interpersonal style. Some therapists are quite comfortable shifting to
a highly structured and directive teaching style, whereas others may favor a
more interpersonal relational process focus in which interventions are delivered in a less directive manner.
Despite personal preferences, therapists are encouraged to expand their
repertoire to use a range of styles and techniques to match to the unique
needs of families. Ultimately, irrespective of whatever style works best, therapists must ensure that new behaviors are practiced in the session. Talking
about engaging in new behaviors without actually having the family practice
the new behaviors during sessions is a common therapist error during the
Behavior Change Phase. To sufficiently learn new behaviors so they can perform the behaviors on their own, families need guided behavioral rehearsal
and feedback on each topic addressed by the change plan.
The Behavior Change Plan
In earlier FFT phases, therapists begin to formulate ideas about particular behaviors and interaction patterns in the family that will likely be targets
of change in the Behavior Change Phase. These targets are informed but not
exclusively driven by referral or presenting problems. As therapy progresses,
13190-09-Ch08_2ndPgs.indd 132
2/8/13 11:16 aM
the plan becomes more definitive, providing a road map that can be followed fairly systematically over a series of behavior change sessions. Targets
of change include family relational patterns and behavioral deficits, as well
as strengths that can be augmented.
Behavior change plans also need to include strategies that are developmentally appropriate for the youth in the family. As youth move through
adolescence, cognitive skills, emotional maturity, and social functioning are
changing, autonomy increases, and parentadolescent communication moves
toward symmetry. Change plans also take into account the intellectual functioning and cognitive development or sophistication of other family members. Implementation of change plans varies according to the relative levels
of complexity and can range from simple, concrete approaches to more intricate or sophisticated techniques using the same match-to-sample concept
consistent with prior chapters. Thus, issues such as how privileges are negotiated or how contingencies are managed vary widely depending on the age of
the adolescent and the developmental levels of each family member.
In typical adaptively functioning families, the power differential between
parents and children changes over time as youth transition from preadolescence to adolescence to young adulthood. Normatively, parents and adolescents engage in more symmetrical, less hierarchical interchanges about family
issues than do parents and younger children. Thus, communication training
and negotiation skills are more often included in change plans with families
of older adolescents because independent decision making and responsibility
tend to increase throughout adolescence in a developmentally appropriate
fashion. Contingency management strategies such as time-out are rarely used
with older youth but are more common with preadolescents and younger
children.
Families often encounter difficulties during periods of developmental
transitions. This often results from parents reverting to parenting behaviors
that worked when the children were younger rather than adopting new parenting strategies that meet the development needs of maturing adolescents.
The difficulties also add to parents levels of stress and reinforce the common belief that the transition to adolescence is a particularly tough one for
both youth and parents. Parents find that the strategies they used when the
child was younger no longer produce the same outcomes. If parents are unable
to adapt and develop new skills, interactions may become increasingly conflicted, hostile, or even violent; parents will likely experience increasing hopelessness and may ultimately give up. Negative coercive cycles; inappropriate
and inconsistent reinforcement; failure to supervise and monitor adequately;
excessive permissiveness; or harsh, punitive, or inconsistent parenting are
all common manifestations of families of youth with disruptive behavior
problems that are likely to be targeted during the Behavior Change Phase.
13190-09-Ch08_2ndPgs.indd 133
133
2/8/13 11:16 aM
Change plans are also tailored to take into account matching-to-sample

considerations so that by the end of treatment, families have begun to function more like the adaptive families within a similar population or environmental context. Single working mothers with disruptive youth, for example,
are helped to develop parenting skills that are similar to those of single working mothers whose adolescents are not disruptive. When youth spend time
with two active parent figures who live separately and who may have their
own new family relationships developing, change plans incorporate attention to these factors. This once again demonstrates that FFT does not pursue
some ideal manifestation of family functioning across all families. Rather,
adaptive behaviors and relationships are built within the context of a given
familys financial resources, extended family resources, unique circumstances,
neighborhood, community, setting, culture, religion, and any other specific
factors that bear on what outcomes are feasible, appropriate, and achievable
for families in the context of matching to sample.
The most common components in the change plan include increasing
positive family activities, improving parenting and youthing skills, providing
communication training, negotiating limits and rules, problem solving, and
managing conflict. Youthing skills include not only compliance and attention
but also appropriate assertion, formulation, and verbalization of possible but
acceptable alternatives to parents (and other appropriate adults) requirements and limits.
Technical aids are frequently used in sessions to facilitate learning and
encourage positive family process. By design, however, FFT programmatically encourages therapists to incorporate any other empirically supported
strategies or devices capable of changing behavior and accomplishing the
therapeutic goals. These can include contingency management, anger management, assertion training, cognitive approaches to mood management,
positive peer selection and relationship building, and development of alternative communication means. During this time, therapists also help individual family members target specific skills that focus on one individual, such
as positive self-talk. However, in FFT, these skills are developed in the family context so other family members will understand what the individual is
doing, support it, and even become coaches (depending on the relational
functions of all involved). Parents and youth often run into conflict when
spending too much time together, for example, but can communicate at a
high rate via texting. When a parent needs to know where a youth is at an
exact moment, the youth can send a live picture if he or she possesses a cell
phone with such capacity. Although such devices may be out of reach for
some families, many have access to technology that can be incorporated into
the therapeutic process.
13190-09-Ch08_2ndPgs.indd 134
2/8/13 11:16 aM
Most of the techniques implemented in the Behavior Change Phase

are not unique to FFT. Rather, FFT is designed to allow clinicians to draw
from the broader literature on evidence-based cognitive and behavioral treatments to integrate other behavior change strategies into FFT as needed. For
example, the therapist may want to include a stress-reduction strategy such
as relaxation training for a parent, the youth, or a shared family activity as
part of the Behavior Change Phase for a particular family. A variety of forms
of relaxation training, including specific elements of progressive deep muscle
relaxation, breathing skills, and imagery, have garnered empirical support
in the literature. Therapists can select a relaxation training protocol on the
basis of strategies they have already learned, the availability of an implementation manual or other therapist guide, or the appropriateness of the protocol
for a particular family (e.g., deep muscle relaxation may be more useful than
imagery techniques for families with more concrete thinking).
Each familys change plan will be different because it will be uniquely
tailored to a specific family culture and the assessment of needed change.
Although communication and problem-solving skills training are considered core behavior change strategies, for example, they may look quite different across families as strategies are implemented in keeping with relational
functions, developmental considerations, and matching-to-sample factors
relevant to each particular family. Other components that may be integrated
into a behavior change plan as needed include anger management, coping with depression and other negative moods, relaxation training, or other
stress-reduction strategies such as assertiveness training, decision making,
and anxiety management.
Empirically supported behavior change techniques associated with each
of these components are merged into the FFT Behavior Change Phase as
needed to address the major issues confronting the family, although no single
family would ever receive all of these components. To maintain FFT as a
brief and cost-effective intervention, the goal is not to increase the length
of treatment by adding myriad components to the behavior change plan.
Instead, the plan is streamlined, focused, and incisive and includes only the
key necessary and sufficient components to address families primary problem
areas. That said, the actual number of sessions in this phase depends on the
family, the treatment progress, and, unfortunately, the availability of funding such as insurance or the families resources. In cases in which financial
resources are still available, FFT can provide more behavior change sessions
and undertake change in more domains. Readers are reminded, however, that
the very strong empirical support for the efficacy of FFT was accomplished in
versions of FFT that involved few sessions (812 with average cases; 1215
with very difficult populations).
13190-09-Ch08_2ndPgs.indd 135
135
2/8/13 11:16 aM
Learning Theories
To prepare for creating change plans that integrate empirically supported interventions into the Behavior Change Phase, it is essential to review
learning theories and how different learning principles have given rise to
cognitive behavioral therapy (CBT) approaches for a variety of clinical problems. CBT modes conceptualize family problems as learned behaviors that
are largely initiated and maintained in the context of the environment.
For example, much research has examined classical conditioning in the
acquisition of problem behaviors (e.g., Davey, 1992; Sherman, Jorneby, &
Baker, 1988). Anger may emerge as a response to stimuli that push family
members buttons or trigger an explosive outburst. Interventions involving
stimulus control may focus on recognizing potential triggers or stimulus cues
and using strategies to increase self-control or avoid situations that place family members at elevated risk for an explosive outburst.
The operant learning perspective (Skinner, 1974) views maladaptive
behaviors as developing and being maintained in the context of the consequences that follow the behavior. Attention, for example, whether through
praise or yelling, can serve as a powerful reinforcement for desirable and
undesirable behaviors. The vast majority of parenting approaches are based
on the operant learning model (ODell, 1974; Patterson, 1971, 2002). The
principles of positive and negative reinforcement, strategies for managing
disruptive behaviors, and related issues such as intermittent reinforcement
schedules or the appropriate ratios of positive remarks versus verbalizations
intended to correct the behaviors of others have been refined over many years
of parenting skill training program development.
The social learning model (Bandura, 1977) incorporates classical and
operant learning principles, acknowledging the influence of environmental
events on the acquisition of behavior. The social learning model also recognizes the role of cognitive processesthat is, how environmental influences
are perceived and appraised in determining behavior (Bandura, 1977). From
a social learning perspective, family members learn behaviors by observing and imitating others (Patterson, 1975). According to the stresscoping
model (R. S. Lazarus, 1966), for example, families may uniformly engage in
maladaptive strategies such as conflict avoidance as a way to cope with the
stress they experience when problems in the family arise. Such poor coping
may stem from modeling the avoidance behaviors observed in others, punishing behaviors delivered by family members if direct confrontation occurs, and
a lack of alternative appropriate coping models. Learning new behaviors and
skills can be facilitated using social learning concepts such as fostering positive attitudes toward the behaviors to be learned and a sense of self-efficacy
to master the behaviors.
13190-09-Ch08_2ndPgs.indd 136
2/8/13 11:16 aM
Thus, CBT uses a variety of strategies derived from classical, operant,

and social learning perspectives rather than being a single unitary approach.
CBT interventions for family-based problems often include recognizing
stimuli or triggers of negative thoughts, feelings, and behaviors and developing change plans that include avoidance of high-risk situations. They
also include altering reinforcement contingencies for wanted and unwanted
behaviors; providing skill building to improve communication and problem
solving; and training in coping skills such as anger management, coping with
depression, and relaxation exercises for anxiety reduction.
Behavior Change Techniques
When moving into the Behavior Change Phase with a family, it is
important for therapists to maintain the familys increased hopefulness,
reduced blaming and negativity, enhanced relational view, and positively
changed attributions about each other. This can be accomplished by highlighting the earlier themes about behavioral and relational patterns as the
therapist sets up the initial behavior change tasks. As the therapist progresses
through the Behavior Change Phase, however, he or she may find it less and
less necessary to review these themes and may be able to jump into behavior
change tasks with only minimal setup.
All Behavior Change Phase sessions have five distinct elements:
1. Prior to introducing a change topic such as communication or
problem-solving skills training, the therapist provides a rationale for focusing on the topic.
2. The therapist presents the main principles or steps of the skills
to be taught. Once again, and with the overarching principle of matching in mind, the first two elements of behavior
change are presented in a way that fits the familys intellectual capacities (they may differ from one another), culture, and
interpersonal styles. Therapists should avoid coming across as
too concrete and simplistic for family members more comfortable with greater detail and cognitive precision but should also
avoid coming across as too academic for family members more
comfortable with being told what to do.
3. The therapist facilitates behavioral rehearsal of the new skills,
including modeling the behavior to be learned (e.g., active listening), providing a negative model of the behavior (e.g., inattentive listening), having the family members participate in
generating examples that they write on a whiteboard, and/or
directing role-plays in which the behaviors or skills are practiced.
13190-09-Ch08_2ndPgs.indd 137
137
2/8/13 11:16 aM
4. The therapist coaches and provides behavioral feedback on the

familys performance.
5. The therapist assigns a practice exercise related to the behavior
change topic that families can work on at home between sessions (i.e., homework).
The following sections describe specific techniques for behavior change.
Positive Family Activities
A vital concern early in the Behavior Change Phase is to enhance the
familys experience of positive change by increasing positive activities and
interactions. By maximizing the success experiences of families, the positive momentum and family motivation established in the Motivation (treatment readiness) Phase will continue and help carry the family through more
challenging behavior change processes. To foster positive family activities,
therapists will likely be able to incorporate information gleaned from earlier
sessions. Common questions asked during the Motivation Phasefor example, What was it like in this family before the problems started 3 years ago?
and What did you used to like to do together?serve the motivational
purpose of focusing families on the idea that all of their interactions were not
always aversive ones and builds hope that if they could enjoy spending time
together once, they might do so again. In the Behavior Change Phase, their
responses to these questions can be revisited.
To begin a discussion of increasing positive family activities, the therapist, as always, offers a rationale or context for the discussion. There is no
script for the rationale. Rather, the rationale is tailored contingently to the
familys experience in therapy. Thus, a therapist might say to a family who
has experienced the loss of a loved one,
Youve all been feeling sad for so long that youve even lost those moments
when you used to enjoy doing things together. One of the things that will
be helpful as you try to cope and support each other at home is to make
sure we plan for getting some good times back.
Alternatively, a therapist could say,

Weve been talking over the past weeks about how you got to the place
where the conflict and stress have taken over everything in the family
and made it so no one wanted to spend time doing the old fun things you
used to do. As you rebuild your relationships, we want to make sure some
of the fun gets back in your family.
Both of these examples are brief, are specific to the familys own experiences, and provide a context of reason to ground talking with the family
about positive activities.
13190-09-Ch08_2ndPgs.indd 138
2/8/13 11:16 aM
Following the introduction of the rationale, therapists can collaborate

with the family to plan positive activities with the family by mentioning
activities they used to enjoyfor example, Remember when you mentioned
you used to have movie night when youd make popcorn on Sunday nights?
I know its been a long time since you did that! Is it something you might
consider doing again? Whether the activity was fishing, going out for dinner, taking walks, riding bicycles, playing games, camping, making cookies,
throwing a Frisbee, working on a jigsaw puzzle, or going to the park (river,
lake, beach), there are invariably activities that the family used to enjoy
that could be tried again. As adolescents get older and interests in the family
change, new activities also need to be explored. It can be challenging to help
the family identify potential activities because negotiating with one another
may feel strange or awkward and it may have been a long time since they
focused on spending time together in a positive way.
Therapists may need to offer encouragement for the family to persist
and take a chance with each other. The possibilities for positive family activities, although perhaps not endless, are nonetheless extensive, and finding
activities that meet the familys needs is a creative process. Sharing interests with one another, such as photography or community theater; pursuing
a physical activity together, such as skateboarding or running; repairing a
car, bike, or motorcycle together; taking a class together; going to church
together; attending Alcoholics Anonymous meetings together; volunteering
at a community center or animal shelter together; or preparing and eating a
meal together, are but a few of the many, many activities we have seen families over the years begin to enjoy again or for the first time.
Given the developmental and experiential changes that have occurred
for youth between the onset of problem patterns and the Behavior Change
Phase of FFT, they may be highly resistant to anything that seems to revert
back to a phase of family life from which they have been working hard to
emancipate. However, with some creativity, FFT therapists have been able to
make the current versions of the activity more age appropriate for the youth
but still within the parents comfort zones. As always, in discussing the family
activities to be pursued, therapists should guide the selections and the form the
activities will take with respect to the relational functions of the family members. For example, fishing and going to a movie are inherently midpointing
activities, with family members focused on something outside their relationship and not talking much to one another. However, fishing can involve family members sitting next to one another in a boat or in folding chairs on the
bank, consistent with closeness. By contrast, fishing can involve some people
fishing upstream while others fish downstream, thereby facilitating autonomy.
In keeping with the elements of the Behavior Change Phase, the therapist
can provide a brief rationale for the importance of increasing positive family
13190-09-Ch08_2ndPgs.indd 139
139
2/8/13 11:16 aM
activities, describe some common activities, ask the family to generate examples of activities they enjoyed in the past or might enjoy exploring together,
and provide coaching and feedback to the family in the development of a
plan for something they might do together prior to the next session.
All family activities should be tailored to ensure that the relational
functions of each family member are respected sufficiently to avoid resistance
or, worse, sabotage. For example, a mother who works late hours and often
spends weekends visiting her boyfriend may be more open to briefer activities such as going to a movie rather than full-day activities with her teens.
For the family of a teen who wields substantial power, an activity that the
teen chooses and the parent is willing to try might ultimately be more successful than an activity a parent suggests. Positive family activities can be
incorporated into homework assignments throughout the Behavior Change
Phase. However, the seeds for growing positive change may be planted even
earlier in therapy. A common homework assignment for early sessions, for
example, is asking family members to secretly observe others in the family
and come to the next session prepared to share one thing they noticed in
each family member that they appreciated. The discussion of this homework
assignment at the next session has multiple purposes, including providing
clues to relational functions in the family and fostering hopegoals of the
Assessment Phase and Motivation Phase, respectively. However, the process
of sharing positive observations and talking about behaviors they appreciate
in one another begins to introduce the idea of enhancing the familys experience of positive change.
Parenting Skills and Parent Training
The foundation of parent training and contingency management is
to help parents use reinforcement strategies to encourage desirable behaviors, use effective discipline techniques to discourage undesirable behaviors,
and allow natural consequences for adolescent misbehavior to occur when
appropriate. The first step in encouraging desirable behaviors is to set the
stage for success by helping parents provide clear expectations for behavior,
overtly clarify limits, and provide the appropriate context for their youth to
comply with instructions and requests. For example, easily distracted youth
often need chore requests provided in writing because they remember the first
request to take out the trash but forget the second and third requests to empty
the dishwasher and rake the lawn. Behavior change sessions may include discussions about the types of chores that are developmentally appropriate and
ways parents can maximize the likelihood that their expectations will be met.
A common parent refrain when discussing chores is He knows what hes
supposed to do; I shouldnt have to tell him, and this view often results in a
13190-09-Ch08_2ndPgs.indd 140
2/8/13 11:16 aM
cycle of parent frustration and lashing out, adolescent resentment, escalating

conflict, and, with time, increasing hopelessness. Asking that the garbage be
emptied before dinner could create a context more conducive for compliance
than reminding the youth late in the evening when everyone is tired and
the family is getting ready for bed.
The use of positive reinforcement, negative reinforcement, planned
ignoring, and a variety of discipline strategies may all be implemented during the Behavior Change Phase when deemed appropriate. On their own,
parent management techniques appear to be more effective with younger
rather than older adolescents. Because FFT is a systemic model and all family
members are included in therapy, choosing and relaying these techniques to
family members must be done in a sensitive and flexible way. The inherently
hierarchical nature of parenting strategies can feel alienating to an adolescent who is in the session and is not feeling that his or her needs are being
met by the parents. The introduction of contingency management concepts
should be carefully considered and worded in such a way that therapists do
not lose their alliance with the youth. In general, the use of these basic parenting principles is encouraged in FFT through incorporation into the more
systemic and collaborative techniques of responsecost techniques and contracting. Therapists should keep these principles in mind, but their application is more commonly conducted through more systemic means than classic
parent training.
The core tools of contingency management involve reinforcement and
punishment. By definition, reinforcement is anything that increases the likelihood of a behavior recurring, whereas punishment is anything that decreases
the likelihood of a behavior recurring. Thus, reinforcement and punishment
are completely separate and independent of one another, with the reinforcement serving to foster or encourage behaviors and punishment used to eliminate or discourage behaviors. In early autism programs, M&Ms were used as
reinforcement for autistic children learning to speak, but if a particular autistic child doesnt like M&Ms, then the candies are not reinforcing because a
reinforcer is defined by the effect it has on behavior. If a child has an aversion to the colors of M&Ms or, worse, has an allergic response to chocolate,
then the M&Ms could be experienced as punishment, serving to suppress or
decrease the likelihood of speech. Similarly, in response to a week in which
an adolescent has met responsibilities at home, a parent could decide to take
the adolescent fishing as a way to reinforce good behavior, but fishing is a
reinforcer only if it serves to increase the responsibility-taking behavior. If
the youth is repulsed by the notion of catching and killing fish, the activity
is unlikely to be reinforcing. Fishing may have been offered as a reward for
good behavior, but as illustrated in this example, a reward is not the same as
a reinforcer. A consequence represents reinforcement only if the behavior
13190-09-Ch08_2ndPgs.indd 141
141
2/8/13 11:16 aM
increases; if the behavior does not increase, then the consequence is not a
reinforcer.
Table 8.1 provides examples of the various types of reinforcement and
punishment strategies that may be integrated into FFT. As the table shows,
reinforcement can be categorized as positive or negative. These are not value
labels. Rather, the terms positive and negative refer to whether the consequence involves the presentation of something (positive) or the withdrawal
of something (negative). Specifically, negative reinforcement occurs when
a behavior is followed by the removal of an aversive stimulus (e.g., nagging stops), thereby increasing that behaviors frequency. The commonality
between positive and negative reinforcement is that both serve to increase
behavior, and hence negative reinforcement is not punishment. Punishment
can also involve the delivery of something (i.e., presenting something aversive) or can take the form of withdrawing something or the cessation of something (i.e., removing something pleasant or desired) as a means to decrease
unwanted behavior, although the terms positive and negative are not typically
used to distinguish punishment involving the presentation or removing of
consequences.
With respect to the delivery of a consequence, then, offering praise
could serve as positive reinforcement, whereas assigning extra chores represents delivery of a punishment. A parent could also reinforce a childs use
of normal voice tone by ceasing to engage in planned ignoring when the
child begins speaking normally after previously whining. The parent could
signal this connect to the child by saying, I have trouble hearing you when
youre whining. I listen better when you use a normal tone of voice. In this
example, the termination of the parents ignoring behavior is a negative
reinforcer if the childs use of the normal voice increases. Loss of video-
Table 8.1
Behavioral Parenting Strategies
Consequence
Something is given
Something is removed
Increases the likelihood of the behavior

Positive reinforcement:
77 Praise
77 Tangibles (food, toys)
77 Activities (movie, games)
77 Allowance
77 Points or tokens
Negative reinforcement:
77 Child is excused from chores or work
77 Nagging stops
77 Tantrum ceases
13190-09-Ch08_2ndPgs.indd 142
2/8/13 11:16 aM
game access after swearing involves the cessation of something (playing a

videogame) and is designed to decrease a behavior; therefore, it represents
a punishment.
Parents can also permit the child to experience the punishing effects of
natural consequences without having to actively provide punishment themselves. For example, when a teen loses his or her cell phone, the natural
consequence is that he or she does not have a cell phone to use anymore. A
parent does not have to provide additional punishment because as long as
the parent refrains from replacing the phone, the consequence of not having
the phone is likely to be sufficiently aversive to encourage more responsible
behavior in the future.
One reason it is important to understand the distinction between
reinforcers as consequences that serve to increase behaviors and punishers
as consequences that serve to decrease behaviors is that families unintentionally or inadvertently reinforce or encourage bad behaviors and punish
the behaviors they would like to see more often. Negative reinforcement
happens all too often in families when nagging, bugging, or other persistent
aversive interaction behaviors result in the person being nagged or bugged
giving in to the demands of the other. Everyone in the family participates
in such behaviors, whether the situation is a parent permitting the youth
to go to a party after days of repeated asking, the father fixing the broken
window or the youth washing dishes in response to the mothers repeated
nagging, or an adolescent getting into an argument with a younger sibling
who keeps bugging him until he gets a response, regardless of whether the
response constitutes positive or negative attention. When someone craves
interaction, an argument can be very reinforcing! The nagging invariably
is positively reinforced whenever family members give in, and thus the
nagging is likely to recur. But the giving in behavior is negatively reinforced because once the person gives in, the aversive behavior stops. This
situation, in which the behaviors of all the parties are reinforced, reflects a
cycle Patterson (1982) referred to as the coercion paradigm. Helping family
members recognize when they are inadvertently providing reinforcement
for undesirable behavior and helping them develop alternative responses
to reinforce the behaviors they desire from others are discussion topics that
can involve the entire family.
Family members may also be inadvertently punishing desired behaviors,
decreasing the probability that they will occur. For example, a daughter excitedly tells her parent about being cast in a supporting role in a school play, and
the parent responds by asking, Who got the lead role? Helping families sort
out when they are inadvertently encouraging or enabling maladaptive behaviors and when they are missing opportunities to encourage desired behaviors
is an important process in the Behavior Change Phase.
13190-09-Ch08_2ndPgs.indd 143
143
2/8/13 11:16 aM
Contracting
Contracting involves having family members identify specific things
they would like other family members to do in exchange for interactions or
behaviors or tangible rewards. This procedure is especially important with
adolescents (as opposed to younger children). Contracting is one of the
most commonly used parentyouth interaction influence techniques in FFT
because it is systemic (e.g., involves considering the idea of reinforcement
or reward for all members of a system or subsystem), and it can be initiated
during therapy and subsequently adapted for use independently at home after
therapy is completed with the referred youth as well as with other children
at almost all developmental levels. In some cultures, the concept of parents
and youth negotiating on more or less equal terms may violate families belief
in relatively impermeable boundaries between parents and adolescents and
values that include a firm parental hierarchical structure. In such families,
contracting or other negotiation strategies may need to be reframed for the
family in terms of helping the adolescent transition to adulthood or learn
how to communicate his or her needs in a respectful way so the parents can
know how to better meet the youths needs or using some other culturally
sensitive approach.
Contracting should initially be conducted within the therapy session
because therapists need to do a number of things to make early contracting as
positive an experience as possible. Therapists need to collaborate with family
members to identify desired actions and rewards that are specific and realistically attainable. A family that decides to contract with an older child to
provide a family trip to Disney World in exchange for good behavior throughout the school year is likely to experience failure. The goal is too global and
distal; the good behavior desired by the parents is too vague to be monitored
and subject to each persons individual definition of what represents good
behavior. The goals of all parties also may not be attainable. The parents
might not realistically be able to provide a trip to Disney World (or they
might provide it regardless of the childs behavior), and unless the end of
the school year is near when the contract is entered, the child will quickly
determine that it is unrealistic to be good for such a long period of time. A
more specific and attainable contract would involve having the child call a
parent to report his whereabouts after school and be home by 6:00 on school
nights in exchange for a desired activity on the weekend.
Again, therapists also need to monitor contracts to make certain they
are attainable based on the functional relationship needs of each participant. Finally, therapists need to monitor the in-session contracting process
to maintain the decreased negativity attained during the Motivation Phase.
To this end, therapists often refer back to specific reframes and themes from
13190-09-Ch08_2ndPgs.indd 144
2/8/13 11:16 aM
the Motivation Phase that were particularly helpful in creating positive

attributions in family members. If communication training was conducted
earlier in the Behavior Change Phase, the therapist models and reminds the
family to use communication techniques during their in-session contracting
discussions.
ResponseCost Techniques
Especially effective with children and preadolescents, the specific
approach identified by Webster-Stratton and Herbert (1993) as responsecost
techniques provides a wonderful framework that helps a parent or parents learn
how to set clear penalties (typically loss of privileges) for inappropriate child
behaviors or failures to perform. Expected behaviors and penalties should
be fair, clearly stated, and augmented by visual aids whenever possible. For
example, if a preadolescent will lose TV time for swearing at her parents, a
chart might be made to represent her normal weekly TV time in such a format
that specific blocks of time can be crossed off the chart for each incident of
swearing. Responsecost techniques should be offered in conjunction with
compatible reinforcers for prosocial behaviors desired in place of the target
inappropriate behavior. The responsecost system will be clearer if the reinforcers for desired behaviors are distinct from the revoked privileges. In this
example, the preadolescent girl might receive a mark on a different area of the
chart for each day that she expresses a problem or angry feeling to her parents
without swearing. The reinforcer for marks on this area of the chart should
not be returned TV time but might be a movie or some other desired activity.
Remember that relational functions are a very powerful motivational
component of most important within-family behaviors. Thus, positive reinforcement (e.g., positive attention to increase a behavior that provides an
alternative way to meet relational functions) can be a very powerful alternative to focusing on the bad behaviors, but it also must match the relational functions of all members. Therapists should help families incorporate
relational reinforcers (e.g., time alone or time together, depending on the
relational function) as well as tangible reinforcers (e.g., snack, book, movie,
money). Everyone needs to be recognized and reinforced, or the new behaviors will not be sustained. Parents are unlikely to persist in using a system that
is aversive to implement, even if the positive change in their childs behavior
is experienced as reinforcing.
Communication Training
Communication training is commonly used in FFT. In some families,
the training represents a focus on a true skill deficit; the family members truly
13190-09-Ch08_2ndPgs.indd 145
145
2/8/13 11:16 aM
do not know the basics of interpersonal communication. In many other families, however, family members know how to communicate quite well (e.g.,
some have been effective teachers, professors, clergypersons, Girl Scout leaders, or even counselors). However, in the current individual, family, and community context, they are unwilling or unable to communicate in the effective
ways they can demonstrate in other contexts. With family members who
truly are characterized by skill deficits, emphasis is on explaining and practicing the positive elements of communication listed below. When instead
the problem is one of performance rather than ability, emphasis is placed on
practicing the reattribution (e.g., reframing) interventions described earlier
and providing constant reminders of the rationale behind positive and effective communication.
Almost every family benefits from various elements of communication
training, but one aspect typically receives greater emphasis, and the different emphases lead to sessions that look very different from one another. It
should also be noted that communication training requires emphasis whenever two powerful members of a family system are unable to resolve problems
verbally. Thus, in two-parent families in which there is serious marital or
relationship strife, communication training requires a special focus within
that marital subsystem, regardless of the developmental level of the referred
child. Marital subsystem is used as a conventional relational form, but the
principles apply to any system in which two adult figures represent the parenting context for a child or even adolescent figures who are in the position
of having responsibility for parenting a child. Note also that in many cases,
two adults do not overtly acknowledge parent status (e.g., a single mother
and occasional live-in boyfriend), but during the Behavior Change Phase,
interventionists must take into account the influence of the nonparent on
the behavior, emotions, and beliefs of the youth.
Positive communication includes the following elements:
77
77
Source responsibility: Needs and reactions are expressed in I

statements, which facilitate the centering of responsibility on
the speaker. Family members are helped to avoid non-I statements such as In this house..., Kids shouldnt..., Its
not right for you to..., and It would be nice if.... Instead,
family members are taught to say, I want... or When [this
particular thing] isnt done, I feel.... Keeping statements at a
personal level reduces blaming and defensive communications.
Source directness: Source directness is the complement of source
responsibility involving the specific identification of you in
expressions. This helps avoid third-person comments, innuendo, and inappropriate generalizations. To be avoided are such
13190-09-Ch08_2ndPgs.indd 146
2/8/13 11:16 aM
77
77
77
77
non-you expressions as No one around here... and (in front

of husband) He never.... In place of this third-person invisible process, families are encouraged to directly say, I dont
want you to... or You are not to... and the like.
Brevity: Communication must be short to avoid overloading
and facilitate listening. Family members are often asked to state
their needs or reactions in literally 10 words or fewer. By requiring members to do this, it reduces unnecessary statements and
the opportunity to blame others or make provocative accusations. Statements such as I want you to help around the house
instead of You never do anything around here except come
home and read the paper, and if you think the lawn stops growing
just because youre at work, youre crazy reduce defensiveness
and increase the opportunity for change. An effective therapist
quickly seizes on the idea that mowing the lawn and doing some
evening chores will provide the husband with distance and private time while giving the wife necessary help, thus providing
desired change without disrupting functions that regulate intimacy levels.
Concreteness and behavioral specificity: Abstractions such as being
responsible must be translated into specific behaviors to be performed at specific times. When trust is only emerging or still is
not present, an ambiguous situation provides too many opportunities for failure. Helping family members translate their feelings
and demands into specifics facilitates negotiation, contracting,
and presentation of alternatives.
Congruence: Family members are helped to present messages
that are congruent or consistent at the verbal, nonverbal,
behavioral, and contextual levels. For example, an assertion
that a husband wants his wife to spend more time with him
should be spoken in a friendly manner, and he must make it
contextually possible by being available. Family members are
assisted by the therapist to provide congruent verbal and nonverbal cues, then helped to learn how to help each other to do
this in the absence of the therapist.
Presentation of alternatives: By presenting alternatives, family members move the atmosphere away from nonnegotiable
demands and help all family members see the benefit of flexibility in their problem-solving attempts. An example is, I want
you home every night at 8:30, or if youd prefer, coming home
four nights at 8:00 and staying out one night until 10:30. Presenting alternatives transmits a message of We can solve this
13190-09-Ch08_2ndPgs.indd 147
147
2/8/13 11:16 aM
77
77
rather than You must solve this for me. They allow the presenter to retain a sense of control yet also provide the recipient
with a sense of having options.
Active listening: The art of active listening as developed by
Rogers (2003) and others involves the presentation of cues
by the listener both during and after the time someone else
communicates. These cues reflect accurate listening and
include eye contact, nodding, leaning forward, and restating
or rephrasing what was communicated in content as well as
in the feelings expressed. Good listening and expressiveness
are not innate skills, however, and must be practiced. At the
beginning of training, it is best to practice active listening one
sentence at a time.
Impact statements: In response to someone elses communication, impact statements provide feedback in terms of personal
reaction that requires no justification from either party. Their
expression helps family members break up what often seems to
be wired-in relationships between feelings and behavior. Examples of impact statements include When you do ______, the
effect on me is _______ and The impact on me when ______
is that I feel _______.
Thus, although improving communication might be a focus for many

families, the process must be individualized in ways that match the relational
functions of that particular parent and that adolescent. In one family, the
implementation of communication change might take the form of close and
connected negotiation of changes so that both parents feel connected and
part of a collaborative relationship with one another. In another family, with
a different relational profile, the same communication changes would look
more disconnected and distanced, with information exchanged via notes
instead of conversation. Figure 8.1 represents the flow of communication elements used to help families develop better skills around negotiation or contingency management versus relationship building and emotion regulation.
Problem-Solving Skills
The rationale for problem-solving skills training should focus on the
notion that a problem is a situation in which an effective coping response
is not immediately available and effective problem solving requires facing
the situation so that the problem does not build up over time and harm family relationships. The specific steps in problem solving include defining the
problem, brainstorming possible solutions, evaluating solutions, selecting
13190-09-Ch08_2ndPgs.indd 148
2/8/13 11:16 aM
FFT Communication flow chart

Assertion
Negotiation
Source
Responsibility +
( I )
Want
Directness
(you
you)
Affect expression &

regulation,
validation,
relationship building
Behavioral
Specificity/
alternatives
Validation
Active
Listening
(you want)
Brevity
Impact
Statements
Feel
Active
Listening
(you feel)
Figure 8.1. Communication training flowchart.
the most promising approach, implementing the solution, monitoring, and

assessing the effectiveness of the selected approach.
The overall problem-solving approach is adapted from DZurilla and
Goldfried (1971). Problem solving is a skill that can be used to develop a
flexible coping repertoire in situations that have not been previously encountered. Problem recognition is crucial, especially when the impulse is to minimize or deny problems. The very act of sitting down, formally analyzing a
problem situation, and coming up with a range of possible solutions can also
be a direct form of coping. Situations requiring solutions can be general (e.g.,
family illness, conflict at school or work), intrapersonal (e.g., feeling lonely,
depressed), or interpersonal (e.g., family disagreements). The idea of formal
training in problem solving is used to accelerate the process of developing
higher-order coping strategies that go beyond situation-specific skills. This
enhances generalization of coping skills beyond the treatment situation and,
in effect, encourages clients to become their own therapists when they are
on their own.
First, the problem articulated by one or more family members needs to
be defined as precisely as possible. Family members should be encouraged
to talk to clarify the nature of the problem, with instruction and guidance
to be concrete and behaviorally specific. It may help to break a problem into
component parts, as it is easier to manage several parts than to confront the
entire problem at once.
Second, it is important to develop a number of solutions to a given
problem, because the first one that comes to mind may not be the best.
Brainstorming involves generating a list of solutions without stopping to
13190-09-Ch08_2ndPgs.indd 149
149
2/8/13 11:16 aM
evaluate how good or bad the ideas are. It is more helpful to write them on
a whiteboard so the entire family can review them together when deciding which one to try. The family should be encouraged to list all of their
ideasmore is better. As more ideas are presented in the open, the family
can consider several possibilities without rejecting any of them too hastily.
A good solution involves compromise in the family. Therapists help
the family identify the most probable and promising approaches, considering
the potential outcomes for each solution and the anticipated positive and
negative outcomes, both long and short term. The therapist considers what
factors may be used as resources to help the family implement each approach
and what factors may interfere with each approach. All of the potential solutions are arranged according to their consequences and their desirability.
The solution that maximizes positive consequences and minimizes negative
consequences is the one to implement first.
Once a solution has been selected and implemented, the therapist revisits the solution with the family in the next session. The therapist helps the
family evaluate the strengths and weaknesses of their approach. If they are
not getting the expected results, the therapist and family refine the solution
or move on to the second-choice solution, following the same implementation and evaluation procedures for the new solution. It is important to assist
families in selecting one problem at a time and using problem solving for
discrete, manageable problems. For example, it is beyond the scope of problem solving to address depression, but problem solving might be useful in
addressing a mothers concern that her daughter is often down on herself
and makes self-deprecating statements. The therapist can help the mother
and daughter brainstorm strategies to generate possible responses from the
other that could be effective in reducing the daughters negative self-talk.
Use of Technical Aids
In addition to providing communication and additional skill training, FFT interventionists prescribe specific activities and behaviors that will
enhance the familys experience of positive change. In particular, interventionists use as many technical aids as possible. These technical aids include
such simple items as sticky notes that can be put on mirrors to remind family
members about a particular behavior; audio recordings of communication
practice sessions that can be taken home for review; commercially available
manuals on parenting; a wide range of similar free information provided by
social service agencies; training in the use of answering machines, texting
devices, and cell phones to leave messages for family members; a schedule of
reminder telephone calls made by a volunteer to families who need additional
structure to change old behavior patterns; and so on. As programs have repli150 functional family therapy for adolescent behavior problems
13190-09-Ch08_2ndPgs.indd 150
2/8/13 11:16 aM
cated FFT formally and informally, the various technical aids and props that
have been adopted to aid in implementation seem endless, and interventionists can become very creative in developing materials that are consistent with
the particular needs, abilities, and resources of the specific population with
whom they deal.
Interventionists also are reminded to be very creative and energetic
with respect to providing specific and concrete resources for families as they
enter the change process. We do not want to send families (many of whom
have only limited resources and few good work habits) out of sessions with
little more than suggestions about how to change behavior. Instead, we are
much more direct and in some ways controlling (or educational) during the
Behavior Change Phase. In fact, FFT agencies often buy sticky notes and
inexpensive audio cassettes to give to families to use between particular sessions. We also often ask social services and educational agencies to forward
pamphlets and other learning material.
FFT interventionists prescribe specific interpersonal tasks, often involving the technical aids. As has been discussed throughout, these interpersonal
tasks (e.g., setting up a specific plan to supervise homework) must be tailored
to the interpersonal needs and abilities of all family members involved. The
following is a recent clinic example: A mother who worked as an accountant
and a stepfather, a manual laborer, were intent on improving their sons
math performance, which was several levels below his current grade. With
respect to the parents abilities, the mother was the clear choice to tutor her
son. However, her interpersonal needs with this son were more distant or
autonomous than were those of the stepfather. The son, in turn, seemed to
have ambivalent needs regarding both parents and expressed this ambivalence through midpointing behaviors. Thus, the FFT therapist suggested
that stepfather and son struggle with the math together, with the stepfather
consulting with the mother when necessary. This interpersonal task was
certainly less efficient in terms of talent but was much more consistent with
the interpersonal need configuration the participants had with respect to
each other. Note also that the sons midpointing function was respected in
that stepfather and son would, in the beginning of the program, work for
only 30 minutes together, stopping even if nothing had been accomplished.
Over time, of course, successful experiences allowed both the stepfather and
the son, and then the mother, to increase positive contact time as well as
improve grades.
This example once again demonstrates the functional nature of FFT;
early behavior change targets are those that can provide successful experiences, even if they are considered modest by others standards. In the long
run, FFT theory asserts that these successful experiences provide a basis
for accelerated future change. In contrast, more impressive but unrealistic
13190-09-Ch08_2ndPgs.indd 151
151
2/8/13 11:16 aM
change goals, if promoted early in the Behavior Change Phase, are more
often associated with failure, frustration, and decreased alliance. Thus, FFT
works first to develop inner strength and a sense of possible self-efficacy in
families, even if only modestly at first, to provide a platform for change and
future functioning that can extend beyond the direct support of the interventionist and other social systems. In the long run, this FFT philosophy
leads to more self-sufficiency, fewer total treatment needs, and considerably
less cost.
The above examples represent some common techniques used by FFT
therapists. However, nearly any structured activity can represent a useful technique in FFT behavior change, as long as the behaviors they create
and maintain are consistent with relational functions. Over the years, FFT
therapists have used a very wide range of cognitivebehavioral techniques,
trauma and experiential techniques developed in other contexts, and already
established cultural practices (e.g., preparing meals together, observing birthday and holiday traditions) as contexts for FFT behavior change. Once they
become comfortable with the core construct of matching, FFT therapists
have found an almost limitless number of techniques available during this
phase of FFT intervention.
Additional Behavior Change Techniques and Frameworks
Although the diverse expressions and iterations of CBT approaches
initially were developed primarily for working with adults, they are increasingly being extended successfully to children and adolescents. In particular,
symptom patterns identified with anger management problems, adolescent
substance abuse, depression, anxiety, and trauma and posttraumatic stress
disorder have been reported and replicated. Because emotions, thoughts, and
behaviors are all linked (A. Lazarus, 1996), various CBT elements allow therapists to intervene in different domains to disrupt maladaptive behavioral
cycles. FFT has taken these diverse contributions, involving a wealth of specific protocols, a step further by integrating them into our family-based intervention and doing so through a relational lens (i.e., relational functions).
Rather than working with only one family member directly on his or her own
behavior, FFT therapists also can intervene with a particular family member to impact the emotions, cognitions, or overt behaviors of another family
member when weekly conjoint sessions cannot be maintained throughout
the course of treatment. This includes an often-overlooked resource in that
youth can be taught, following a successful Motivation Phase for all family
members, to influence positively and proactively the emotions, cognitions,
and behaviors of a parent or other caretaker. This principle also extends to
larger systems, which are addressed in the Generalization Phase.
13190-09-Ch08_2ndPgs.indd 152
2/8/13 11:16 aM
As standalone treatments, cognitive and behavioral approaches with

children and adolescents usually are short-term in duration (often fewer than
10 sessions). They focus on teaching young people and their parents specific
skills. In contrast, when embedded in the FFT Behavior Change Phase, various individualized CBT elements can be shared with the family or taught in
even less timeoften a specific technique can be mastered in one session
with follow-up refinement in a second.
In addition, in the conjoint family context, several specific patterns
involving the referred youth, the parents, and even siblings can be addressed
together in an integrated manner. The therapist, parents, and child or adolescent develop goals for therapy together and track progress toward goals in
session and as homework. This process can and usually does extend to more
domains both within the family and later in the community as the Behavior
Change and then Generalization Phases unfold.
As treatment progresses, parents and youth not only are led through and
taught various behavior change strategies but also are encouraged to develop
their own. Often FFT therapists can facilitate this process by developing
short summaries or lists of specific systems for analyzing problem behaviors
that can be given to family members, used in session, and taken home for
additional homework. Such lists focus on the circumstances, antecedents, or
triggers that precede the problem behaviors, the cognitive beliefs or thoughts,
the physiological and affect components, and the relational contexts present
when the behaviors occur. For example, a rebuke by a teacher at school may
trigger an adolescents anger outburst. The therapist can explore in detail
with the family the thoughts and feelings that were occurring immediately
after the rebuke. Next, therapists can identify and clarify the specific response
that characterized the anger outburst and the positive (reinforcing) and negative (punishing) consequences (e.g., I felt good telling her how I felt, but I
have to stay after school for a week) that accrue.
At times, the typical behavior change strategy will not fit the needs
and abilities of the family, and therapists need to be creative. Consider an
adolescent referred for truancy and repeated citations for vandalism (e.g.,
property damage, graffiti) and shoplifting. A contingency management
approach focusing on reinforcers for desirable behavior and punishment for
bad behavior has been used with some success in such cases, but if the parent and youth have a long-term relationship pattern in which the youth is,
hierarchically, in a more powerful position, the likelihood that the parent
can and will assume an authoritative position to set and apply contingent
consequences is extremely low. As a result, if such a specific behavioral intervention seems necessary and the only option available, then the system must
be set up using another available parent figure in the youths natural environment or introducing an external source to manage the contingencies. This
13190-09-Ch08_2ndPgs.indd 153
153
2/8/13 11:16 aM
could involve a juvenile probation counselor, a friend or staff member from

church, or even a former spouse not living with the youth but willing and
able to play such a role.
A specific behavior change example involved a young gay man referred
for fire setting, including a prior attempt to set fire to a caseworkers home.
At the time of referral, the youth was in a juvenile justice detention facility
charged with arson, and he was being bullied by other youth in the facility.
Even with staff monitoring and security protocols in place, the facility was
not a safe environment. Hence, a reentry plan involving his mother was
put on the fast track. Unfortunately, before his incarceration, the youth did
a lot of acting out to elicit attention from his mother (a connecting relational function), and she frequently created distance with the youth through
such patterns as coming home tired from work and going to bed after telling
her son, Dont bother me. She also, on occasion, would go to a casino in
another town and stay for the night without letting him know in advance.
Also, there were no other adaptive resources for this young man, given his
history. Thus, to begin a transition to home that had any chance of success,
relatively intensive behavior change plans were called for, but they needed to
be consistent with the mothers and sons relational functions: distancing and
contacting, respectively. The challenge was how to allow the son to experience a greater connection with his mother in a way that was consistent with
her autonomy needs. To accomplish this, some additional information was
taken into account.
First, the mother had reported anxiety symptoms associated with coming home and going to bed. As a result, the FFT therapist, in a family session held in the juvenile detention facility, trained the son to implement
progressive relaxation techniques for the benefit of his mother. This literally
involved giving him scripts and role-playing them in session and instructing
the mother that all she had to do was close her eyes, relax, and listen. This
gave her a sense of distance (and of no responsibility for her son, consistent
with her behavioral history) but gave him a way to be better connected with
her but without acting out. Further, his connection was through positive
relational behaviors rather than acting out for attention.
We also worked on a Generalization Phase activity for the youth that
was separate from home and mother yet gave him a vehicle for attachment
to another adult. In this case, the therapist contacted a local large hotel
and explained the situation to the food manager, but also reassured him that
family sessions were ongoing and that the therapist could be contacted at
any time the manager thought necessary. The therapist also reminded the
manager that he did not have to pay for this youth to work in the kitchen if
he would be willing to assign him as an assistant to an appropriate person on
his kitchen staff. A woman who worked in the kitchen was a mother whose
13190-09-Ch08_2ndPgs.indd 154
2/8/13 11:16 aM
children were moving away but still needed financial help from her. Thus,
helping a child was already consistent with her value system and, while helping with this youth, she also received help with job-related kitchen duties in
return. The therapist also shared with the manager that he and the female
employee should always feel free to say and do what they felt was right but
asked that they also recognize that this young man had already declared himself gay and still needed acceptance. The woman understood, accepted, and
was even enthusiastic about helping this lost young man. As a result of the
therapy experience, the youth ended up enrolling in a community college
cooking school.
These examples make it clear that the Behavior Change Phase is neither ritualized nor boring! Behavior change requires considerable creativity,
an understanding of each individual family, an understanding of each familys unique configuration of relational functions, and a diverse repository of
specific change strategies. No one can give the therapist a prescription for
how to integrate the vast bodies of knowledge that have been accumulated
over many years, in many cultures, and in many contexts with respect to
specific evidence-based behavioral techniques. Families just want the conflict
and pain to end and the bad behaviors to stop. The Behavior Change Phase
provides the latitude and flexibility for therapists to match strategies and
techniques to individual families to bring them as close to their goals as they
can. In the process, therapists can decrease and eliminate the danger referred
youth pose to each other and others in the community and enhance their
ability to function well in their families and communities.
13190-09-Ch08_2ndPgs.indd 155
155
2/8/13 11:16 aM
13190-09-Ch08_2ndPgs.indd 156
2/8/13 11:16 aM
9
Generalization Phase
In the Generalization Phase, the Functional Family Therapy (FFT)

therapist extends or exports family functioning into a variety of community
systems. The expectation is that facilitating and managing appropriate links
to adjunctive services often (or usually) must be developed for the treatment
effects to be generalized outside of the treatment context and sustained
over time. In doing so, the therapist helps anchor the family and the family
members to a larger supportive community. As in prior phases, it is assumed
that if these interventions are implemented without consideration for the
family relational functions, these efforts will fail. That is, to simply wrap
services around a family or family member without considering the impact on
family functioning is to risk destabilizing an already precarious family process.
In this chapter, we describe the goals and tasks, therapist characteristics and
focus, and indicators of success for the Generalization Phase. Throughout
DOI: 10.1037/14139-010
157
13190-10-Ch09_2ndPgs.indd 157
2/8/13 11:16 AM
these descriptions, we specifically note how interventions are tailored to

match the unique characteristics of families, relational functions, and systems
that are involved in the lives of youth and families.
Goals and Tasks of the Generalization Phase
Generalization is so named because this phase consists of consolidating, expanding, and developing flexibility and creativity around the skills
developed in the Behavior Change Phase. As noted in Table 1, the primary
goals of the Generalization Phase are to maintain and expand individual
and family change and facilitate change in multiple system links. In doing
so, the therapist focuses on helping family members sustain the new skills
they have learned and generalize these skills into new situations that arise
in the family as well as in different environments and contexts beyond the
family. By consolidating and expanding the familys new behavioral repertoire, the risk for recidivism or relapse to former disruptive or problematic
behaviors or disturbed patterns of interaction in the family is significantly
diminished.
Therapist Characteristics: A Relationally Based
Clinical Case Manager
Although FFT therapists in the Behavior Change Phase rely heavily on
structuring skills to help families learn new behaviors, in the Generalization
Phase, therapists become more flexible and more supportive of the familys
experimentation with new skills they have learned, encouraging family
members to take the initiative in implementing or adapting their skills to
better fit their familys needs. This strategy is based on the well-established
principles of learning theory that remind us that long-term sustainability of
new patterns requires careful and precise practice at first but then more distributed practice, more variable reinforcement, and expansion of the ways
and settings in which the behavioral pattern is expressed (Kazdin, 2005). An
oversimplified but useful characterization would describe the FFT therapist
during the Behavior Change Phase as a fairly strong and directive teacher and
leader. By contrast, during the Generalization Phase, the therapist becomes
more of a supportive clinical case manager or facilitator. Although there are
few opportunities for modeling behaviors directly, the therapist undertakes
considerable role-play with family members to practice productive ways for
helping them deal with community agencies and context.
13190-10-Ch09_2ndPgs.indd 158
2/8/13 11:16 AM
Intervention Strategies in the Generalization Phase

The specific focus and activities of the therapist during the Generaliza
tion Phase are tailored to the unique intra- and extrafamilial strengths and
weaknesses of each individual and family. The therapist continues to be guided
by an understanding of the relational functions of family members both with
respect to each other but now with respect to important community resources.
That is, all of the interventions in this phase are designed and implemented
in a manner sensitive to the unique needs of each family, especially their
relational functions, as well as their resources and skill deficiencies.
Accessing appropriate formal and informal community resources to
expand or generalize to is one of the primary activities of this phase. The
therapist focuses on anywhere family members intersect with the community or environments, and interventions use the behavioral competencies
developed during the Behavior Change Phase to generalize to these outside
system relationships. In addition, the therapist uses any relevant existing or
new resources to facilitate or support positive change. This might include
facilitating a youths bonding to school, addressing a parents attitudes about
peers and school, building youth and parent skills in negotiating extrafamilial
systems (e.g., peer refusal skills, communication with probation counselors
or school personnel), or connecting family members to prosocial support
systems (e.g., Alcoholics Anonymous). In addition, the therapist helps the
family identify or anticipate future intra- or extrafamilial stresses and develops
plans to enhance the likelihood of successful resolution of these challenges.
The possibilities for planning are limitless. Examples include planning for
the return of a sibling from a residential or detention facility, the youths
graduation from high school, the beginning of a job, or the process of getting
a drivers license.
At first, the FFT therapist must lead the way in prescribing and suggesting specific ways for the family to extend behavior change strategies into the
community. Sometimes this is necessary because family members have such
a long way to go conceptually, emotionally, and behaviorally. At other times,
community resources often report being fed up or having given up on
high-risk families, especially those with members who have been obnoxious,
defensive, unmotivated, and sometimes even threatening. Using their best
community linking skills, FFT therapists thus do quite a bit of the initial
outreach; therapists want family members to experience as positive a context as possible. However, therapists also move quickly to work with family
members to undertake these processes themselves. Below, we provide more
detail about intrafamilial and extrafamilial interventions during the General
ization Phase.
generalization phase
13190-10-Ch09_2ndPgs.indd 159
159
2/8/13 11:16 AM
Working With the Family

FFT therapists do not wait for family changes to be complete before
they move into multisystem-focused generalization. In fact, another way to
conceptualize the Behavior Change Phase is that, to a significant degree, it
represents a focus on specific but somewhat narrow behavioral domains that
prepare the youth and parents (and sometimes siblings) to be able to relate
effectively and positively to protective community resources. Therapists do not
teach youth how to read, for example, but often in the Behavior Change Phase
they address the preparatory steps necessary to help youth benefit from other
sources of reading skill development. Whatever specific target is addressed
in the Behavior Change Phase, once these are better managed, therapists can
then work to develop or find ecosystemic opportunities that will facilitate
further skill development in the youth and parents or parent figures. For
example, with respect to dealing with negative peers, first therapists facilitate
anxiety management, communication skills, and refusal skills in the home.
Then, during the Generalization Phase, they can help the family develop similar
skills in the community. Regarding community challenges, FFT therapists often
find themselves role-playing teachers criticizing the youth, role-playing stressed
case managers belittling the parents, role-playing aggressive peers challenging
or bullying the youth, and creating other types of challenges specific families are
likely to face.
FFT therapists may find themselves revisiting already developed themes
and perhaps even developing new ones while continually evaluating the
prescribed changes in terms of relational functions. For example, a youth
who is autonomous with respect to his or her parents and who is developing
positive skills to maintain autonomy but in a healthy manner in the home
may not have the same relational function of autonomy with male and female
peers. Because the skills (cognitive, emotional, and behavioral) are usually
quite different for autonomy- versus interdependence-based relational functions, an entire new set of skills may need to be developed in relationships
outside the family. Of course, this can be quite challenging because therapists
rarely have the peers, teachers, and other members of the community directly
in front of them in the same way they have been able to work with youth and
parent figures conjointly.
Risk for recidivism or a lapse back to former problem behaviors or inter
action patterns can threaten the gains families have made. Active planning for
relapse prevention, defined more broadly here than the specific use of the term
in the drug treatment literature (Witkiewitz & Marlatt, 2007), is essential for
a successful Generalization Phase. The following are some generic steps that
we have found to be useful in helping families plan for future stresses and
challenges and avoid relapses to referral problems:
13190-10-Ch09_2ndPgs.indd 160
2/8/13 11:16 AM
77
77
77
77
77
Identify situations in which the problem has occurred in the

past and high-risk situations in the future.
Be as precise as possible about the specifics of setting, internal
representations (emotions, attributions, physiological states),
and family or environment context.
Identify or develop strategies to use when facing this situation.
Be sure that the strategies are consistent with family members
relational functions.
Rehearsepractice in the session.
Predict the possibility that the problem and the previous
maladaptive responses may occur, but reframe this relapse in
advance, and map out steps to take if it does.
Working With Existing Community Links

At the point of referral to FFT, most youth and families already have
links, both positive and negative, with diverse community systems. Therefore,
it is important to thoroughly assess the risk and protective factors that are
most relevant to each particular family. Interventions often first link the youth
or family with resources expected to have a positive impact on maintaining
treatment gains, including peers who are likely to have a positive influence,
juvenile probation counselors or probation supervisors, or school personnel
willing to help. Then the emphasis shifts to extending parent and youth skills
developed during the Behavior Change Phase to generalize those skills to
relationships outside the family. In doing so, therapists sometimes also work
directly with those community resources to help them anticipate possible
problem triggers that remain.
At the same time, FFT therapists systematically identify ongoing negative
influences and begin to decrease their availability and impact. Often, this is
best accomplished by creating new positive community links that can compete
with, if not replace, the negative influences, such as fostering healthy activities
or the development of relationships with prosocial peers. These efforts are
implemented in ways that are consistent with relational functions. For example,
a youth who is quite autonomous from her single-parent mom but heavily
involved with negative peers and perhaps a gang-involved boyfriend will
respond very poorly to interventions that increase significantly her required
time at home. Neither will she respond well to interventions that decrease
significantly her interactions with peers. However, instituting dense positive
peer programs (e.g., community teen theater program, group peer counseling,
group-based after-school programs, culture-focused awareness groups) will meet
with much less resistance. Similarly, to facilitate maternal tracking of highly
autonomous youth, therapists can integrate checklists, notes, texts, and reports
13190-10-Ch09_2ndPgs.indd 161
161
2/8/13 11:16 AM
from others such as group leaders into the plan, minimizing high rates of
direct and often emotion-based contact between mother and adolescent.
Developing New Community Links
The focus on multisystemic resources is not new. Traditional social work
approaches have included a heavy community focus, including problem
solving how to link potential resources to people in need and facilitating the
establishment and strengthening of those links. In fact, the role of the FFT
therapist in this phase has been described as family case manager rather than
family therapist. This phase of FFT often involves more time on the telephone
with community resources than direct session time with the family. Also during
this phase, the treatment manual is augmented by lists of each specific communitys resources, their requirements regarding service, and contact persons.
As therapists continue to work in particular communities, they also reach out
at a personal level, sometimes revisiting relationships they already have with
community resources and sometimes working hard to develop new ones.
Examples of community-based resources often used by FFT therapists
include but are by no means limited to, parenting classes, resources for rent
assistance, community or religious institution support systems and groups,
positive social media resources, school-based and after-school programs for
specific academic issues, and 12-step facilitation programs. In other words,
the Generalization Phase of FFT represents good old-fashioned social work
in the best meaning of the phrase. It requires specific skills and attitudes on
the part of therapists and the systems within which they work. For this effort
to be successful, therapist salaries and treatment system reimbursement must
support these activities; if therapists are paid only on the basis of therapy sessions
conducted face to face, they will not be able to engage successfully in this case
management phase of FFT.
Indicators of Success: Moving Toward Termination
Maintenance of within-family changes and generalization to community
contexts are the primary indicators of success in the Generalization Phase.
At the same time, increased independence from the therapist is another
indicator of successful resolution of this phase. For example, one important
criterion for considering positive termination is the spontaneous appearance
of family memberinitiated new skills, techniques, and strategies that they
have considered trying on their own and perhaps even tried between sessions.
This, as an aside, is tremendously rewarding for therapists who have felt the
pressure of motivating families for change and then directing that change.
13190-10-Ch09_2ndPgs.indd 162
2/8/13 11:16 AM
Ideally, evidence of successful generalization and independence indicates

the familys readiness for termination. However, in the real world, sometimes an
arbitrary number of sessions has been imposed. For example, a judge, probation
officer, or school official may require that the youth attend 12 sessions as
an alternative to being sent to detention or removed from school. Even when
such arbitrary limits have not been placed, however, with high caseloads,
there often is pressure to complete a familys treatment in a short amount of
time. Insurance and other contractual limitations also may exist.
Despite these external realities, FFT is a short-term intervention with
specific criteria to help therapists and families take steps that will ensure sustainability after FFT is completed. The endpoint of FFT treatment is based on
behavioral, cognitive, and emotional improvement. Termination is dependent on good progress through each phase of FFT, specifically, the attainment
of phase-linked goals. These goals are concretely and behaviorally based but
overall are better considered as stepping stones to positive living rather than
the attainment of some ideal version of youth and family functioning. In
FFT, the ideal goal is becoming no longer problem driven and instead being
normal.
Helping Challenged Families Become Normal
Normal teens argue with their siblings, and normal parents sometimes
lose it and say inappropriate things to their children. Normal youth push limits
on curfew, some are underachievers, and some even hang out unproductively
with other youth the parents may not prefer. Normal role-strained mothers
sometimes choose to devote their time to a work demand rather than their
children. Such markers alone do not create delinquency, school dropout,
violence, and drug abuse. The therapists job in FFT is to help troubled families to become normal. Arguing and disciplining may be chaotic and even
unpleasant, but when it occurs in adaptive, nonproblem families, violence
and other detrimental manifestations that can have long-lasting negative
effects are absent. Even youth with no serious mental health or behavioral
problems can be a challenge to get going in the morning; some even skip a
class now and again. These are not ideal or preferred situations, but youth and
families who can negotiate the journey of growing up, struggling with independence, managing considerable negative emotions, and getting to school
at an acceptable level can and usually will end up being productive and nonviolent members of modern complex societies. In fact, many youth, like many
parents, ultimately will learn to manage alcohol, disrupted relationships, and
even tragedy. Many will learn to dispute issues, sometimes with passion or
even anger. However, they learn to do so without the extremes of emotional
or behavioral expressions that damage themselves or others. The therapists
13190-10-Ch09_2ndPgs.indd 163
163
2/8/13 11:16 AM
job in FFT is not to create ideal families, only normal onesjust as many
therapists live in normal rather than ideal families.
Using this standard, during the Motivation Phase, all family members
need not attain glowing and positive attributions about one another. However,
the negativity, distrust, and feelings of abandonment and betrayal must be
reduced sufficiently that they are able to once again engage in positive interactions that are rewarding for all. During the Behavior Change Phase, not all
youth become avid readers who carefully do homework without being told,
but they are helped to develop enough behavioral skills that they can learn
what they need to learn and attain goals consistent with their needs and those
of the culture and society around them. Parents need not become smooth and
elegant with parenting, but they do need to learn how to parent in productive
ways associated with positive outcomes. In the Generalization Phase, neither
youth nor their parents are required to embrace or even agree with everyone
in the community or in the systems with which they are involved. However,
therapists do target their learning to teach them how to deal with major differences they may have with the community or systems in ways that are not
destructive to themselves or others.
To be clear, FFT works to eliminate behaviors that are dangerous and
illegal, and, in the process, FFT works to build in as many strengths as possible
to enrich the familys protective factors when they face the inevitable challenges that they still will face. Often these challenges are more severe than
we as therapists will have to face in our own lives and possibly more difficult
than we ourselves might be able to manage. However, many of our referred
families have histories that have also provided them with resiliencies that
may surpass our own as well.
How Much Change Is Enough?
Judges, probation counselors, educators, and public health workers often
provide all the needed goal anchors. In our experience, educators do not ask us
to make sure these youth get into a top-ranked university. Correctly, however,
they do expect us to do what is necessary so the youth are open to learning,
have resources in place when they face challenges in that process, and have
developed the basic home-related skills to function in school. Judges do not
ask us to turn youth or the parents that appear before them into community
ideals. Rather, they ask us to do what is necessary so I dont have to see this
kid, in handcuffs, in front of me again. They ask us to help a parent become
a positive resource and an agent of positive control for the youth. And public
health workers do not ask us to ensure that all the youth are married before
they have sex. However, they do ask us to help youth develop the attitudes
and parenting processes that prevent (or stop) unprotected sex with multiple
13190-10-Ch09_2ndPgs.indd 164
2/8/13 11:16 AM
partners and drug use and abuse. The goal is to help families become open to
any positive resources in the community that can provide needed support.
As FFT comes to an end, termination is best considered a positive
launching pad for healthier, happier, and more productive youth and families.
FFT therapists review, informally or formally, the lists of risk and protective
factors relevant for the particular family they are seeing, and they make a
judgment that they have helped the family develop protective factors and
community supports sufficient to support positive future behavior patterns.
They also ensure that the risk-related processes that were relevant to pretreatment maladaptive functioning are significantly reduced or eliminated.
If a parent continues to abuse alcohol or marijuana, for example, we ensure
that other protective factors are in place so that the parent risk will not
inevitably produce youth dysfunction. Of course, therapists also, especially
during the Generalization Phase, work to help such parents attain sobriety.
However, if the parent is unwilling or unable to change during the short time
therapists see him or her in FFT, therapists are not willing to give up on the
goal of doing what they can for the referred youth to be able to function well
even with a drinking parent.
Similarly, if a youth referred for delinquency still exhibits symptoms of
attention-deficit disorder, therapists ensure that protective factors ranging
from psychopharmacological to external structure and internal coping strategies
are in place so that school failure need not be inevitable. Whatever issues or
concerns have been noted during the course of treatment, therapists ensure
that sufficient internal, within-family, and external protective factors have
been developed and strengthened so families can deal with the inevitable risk
factors that continue to surround them. In this way, FFT is an approach that
accepts people where they are and develops positive coping strategies for them
to be successful. Not all kids with attention problems inevitably fail, not all kids
with alcoholic parents become juvenile delinquents or alcoholics themselves,
and not all youth with a parent who has anger problems inevitably become
violent themselves.
Are there hard and fast criteria and rules for successful FFT? Obviously,
yes! We have reviewed them for each phase. Although FFT does not have a
set formula for independently determining what those criteria must and will
be for any given youth and family, the model provides a road map to follow so
that as communities, states, neighborhoods, and cultures each set their own
standards, FFT works within the prevailing contexts to ensure that families
can match the expectations in ways that are healthy and adaptive for the
families in those settings.
13190-10-Ch09_2ndPgs.indd 165
165
2/8/13 11:16 AM
13190-10-Ch09_2ndPgs.indd 166
2/8/13 11:16 AM
10
Anthony: A Case Example
In this chapter, we provide a case example of Anthony, an adolescent

with a history of behavioral problems at home, at school, and in the community. This case description is representative of the referrals typically received
by programs offering Functional Family Therapy (FFT). Moreover, elements
of this case are relevant to the wide range of families that are seen by FFT
therapists, from prevention cases that have yet to reach the level of severity
of problems exhibited by Anthony to more severely disturbed youth and families presenting with severe behavioral problems and co-occurring psychiatric
disorders. The therapist for Anthony and his mother was a licensed mental
health counselor with 3 years of FFT experience. She was practicing at a nonprofit child and family services agency that had funding for FFT services from
the state department of juvenile justice for delinquency prevention services.
Youth on formal probation were referred from the county probation system
DOI: 10.1037/14139-011
167
13190-11_Ch10_2ndPgs.indd 167
2/8/13 11:16 AM
as a result of probation violations. FFT was an alternative treatment option

for youth who would otherwise have been placed in residential treatment.
Referral Information and Family Demographics
At the time of the referral for treatment by his juvenile probation counselor, Anthony was a 16-year-old boy who had repeated curfew violations and
had failed to complete required community service hours. Anthony had a history of petty theft, vandalism, and school problems and had been on probation for 2 years prior to his referral for FFT services. He was regularly missing
classes in school and had received a recent truancy citation. He was described
by his probation counselor as being aggressive toward male authority figures.
Referral information and documentation included a risk and protective
factor assessment completed by the probation officer on the basis of Anthonys
offense record, previous treatment interventions in which he had participated,
and basic demographic information on Anthony and his biological mother,
Lynn. According to the referral summary, Anthony resided with his mother
and younger sister. His mother was not married or involved in a current relationship. She was the sole financial provider of the family and had been working several jobs. There were no other known family members in the area, and
the referral information mentioned only that the biological father and mother
had never been married. The whereabouts of Anthonys father was unknown.
Anthonys past school performance was described as average, and his
behavior and social interactions with school officials and peers were generally
positive. The year prior to his initial probation referral, however, Anthonys
grades began to decline, he became increasingly truant from school (2 days
per week), and he had multiple incidents of fighting with peers. According
to his mother, Lynn, Anthonys behavioral problems appeared to have begun
around the time his biological father contacted him for the first time after
several years absence. She also reported that Anthony and his father had a
tenuous relationship and that his father had had sporadic contact with him
throughout his life. His mother and father were never married and had a
history of domestic violence. The relationship between Anthony and his
mother was described as volatile by school officials, who were concerned that
Lynn had lost control of her son.
Engagement Phase
Two activities form the engagement phase: engaging pretreatment systems and engaging the family.
13190-11_Ch10_2ndPgs.indd 168
2/8/13 11:16 AM
Pretreatment Systems Engagement

An initial goal the Engagement Phase was to engage the county probation system to establish a collaborative relationship with the referral source
and engage all relevant family members in the treatment process. The therapist already had a good relationship with the referring probation unit. That
relationship had been established when the agency first began offering FFT
services to adolescents, and it included several of the probation supervisors or
counselors. Therapists at the agency were required to maintain collaborative
relationships with the probation counselors by implementing a consistent
communication process between them. The FFT program ensured that the
probation counselor would receive a monthly report on the progress of the
adolescent in therapy. Probation staff typically participated in discharge and
aftercare planning sessions with the therapist and family to continue to maintain and sustain positive changes the adolescent had made.
In the case of Anthony, the therapist called the probation counselor
immediately upon receiving the referral. The therapist had several goals in
this initial contact. The first was to let the probation counselor know that the
family had completed the intake process and been assigned to a therapist.
The second goal was to find out more information about the mother and
son, including the nature of the referral problem as well as the probation
counselors impressions of their strengths and weaknesses. Given the length
of probation, it was not surprising that the counselor exhibited quite a bit of
frustration about the case. He described numerous problems with both Lynn
and Anthony. For example, he stated the following about Anthony: Hes
stupid...well, at least he makes stupid decisions. But I think hes actually
pretty sharp. But his mother hardly parents him.
A third related goal of this call was to gather information about the
conditions of probation and general expectations of the probation counselor,
including behavioral plans, curfew expectations, and frequency of visits
with the counselor. Finally, the therapist used the call to provide information about the goals of FFTfor example, to improve school attendance,
eliminate delinquent behaviors, and establish a communication plan with
the probation counselor. As noted above, the agency already had instituted
a regular monthly report to juvenile probation, so this call merely served to
remind the probation counselor about this report.
Family Engagement
To maximize the familys engagement in treatment, the therapist contacted the family immediately after contacting the referring probation counselor, speaking with both Anthony and his mother to begin engaging them
anthony: a case example
13190-11_Ch10_2ndPgs.indd 169
169
2/8/13 11:16 AM
both in treatment. In reviewing the referral information, the therapist recognized the importance of speaking directly to Anthony to set up the initial
appointment. He had already had past negative experiences with school officials and teachers, and the therapist wanted Anthony to experience, even
if only by phone, that his perspective was valued and respected. Also, information from the probation counselor suggested that Lynn did not have a
hierarchical or highly connected relationship with Anthony. Therefore, the
therapist was not confident that Lynn would be able to bring Anthony into
treatment. So instead of working directly through Lynn to schedule the initial appointment (as is the case with many agencies), the therapist reached
out directly to Anthony.
During the first telephone conversation with Anthony, the therapist
introduced herself to Anthony and provided information about how she had
received the referral from probation. She asked him directly to tell her what
he knew about the referral and his views about treatment, both in general
as well as for this specific episode. Anthonys response was respectful but not
expansive. For example, he said that the probation counselor wants me to
stop being a problem. The therapist acknowledged Anthonys statement
by noting that he was right in that the conditions of his probation involved
increasing his school attendance and eliminating his delinquent behaviors.
However, the therapist shifted the focus back to Anthony by asking him,
What is it that you would like to have happen? Anthony responded by
saying, I want to get everyone off my back. I am sick of being on probation.
The therapist used this opportunity to maximize Anthonys expectations that
therapy could work to benefit him directly by noting that this could be
something that she could help him with.
The therapist also expanded the focus from Anthonys referral problems
by beginning to focus on his family. She again acknowledged him by noting
that he said one of his goals was to get everyone off his back and then asked,
Does this include getting your mom to stop being so concerned about you?
As is evident in the choice of wording, the therapist was already shifting the
focus from nagging or overinvolvement to something more nurturing. This
also shifted the focus from behavioral goals to relational goals. During this
conversation about his relationship with his mother, the therapist identified
that one of his strengths was that he was very respectful of his mother. He did
not openly criticize her, and he seemed genuinely interested in meeting her
expectations for him.
In contrast to the initial ease the therapist had in contacting Anthony,
she had to make several phone calls and leave several messages before finally
conversing with Lynn. During their first conversation, the therapist recognized
the importance of offering a sense of understanding and respect for Lynns busy
schedule by emphasizing how well she was managing working several jobs and
13190-11_Ch10_2ndPgs.indd 170
2/8/13 11:16 AM
still finding time to spend with her children. In doing so, the therapist was
concerned that Lynn felt guilty or blamed by the system for her sons behavioral problems. Therefore, on multiple occasions, the therapist highlighted the
moms commitment to providing the best for her family and presented herself
as an ally in helping reduce the problems her son was experiencing.
Both Anthony and Lynn agreed on a date and time for the first appointment 4 days following the phone conversations. On the basis of their reactions during the call, the therapist felt confident that Anthony and Lynn
would be at the home for their session. Nonetheless, on the day prior to the
session, the therapist called them both and left reminders on their voice mail.
The therapist did not press the issue of Anthonys 6-year-old sister participating in the session as she was not seen as key to the treatment process, was not
described as having any ongoing behavior problems, and had no relationship
difficulties with Anthony or Lynn.
Motivation Phase
As noted in Chapter 6, the goals of the Motivation Phase are to decrease
negativity and blame, increase hope, and build balanced alliances. This is
accomplished by systematically creating and infusing a strength-based relational focus through the use of change-focus and change-meaning interventions. On the basis of the information provided by the referring probation
counselor, the therapist was able to prepare for the first session by anticipating some motivational strategies, including relational focus and reframing, to implement in the first session. For example, given that the timing of
Anthonys problems coincided with the contact with his biological father,
the therapist was ready to introduce reframes or themes about his connection
to family members. This preparation helped the therapist move forward more
quickly with the family.
Session 1
Although the therapist had reached out directly to Anthony prior to
starting treatment, he was not present when she arrived at the home for the
first visit. Lynn explained that Anthony had decided that therapy is worthless and that he was not coming downstairs from his room. Lynn appeared
withdrawn and lethargic and had flat affect. She reported having just finished
working a double shift. It was obvious to the therapist from Lynns tone of
voice and the sarcasm she used in repeating what Anthony said that she was
not pleased with her sons behavior. The therapist refrained from expressing
empathy toward the mother or siding with her vis--vis Anthonys behavior
13190-11_Ch10_2ndPgs.indd 171
171
2/8/13 11:16 AM
but instead acknowledged and relabeled her by thanking her for her attendance and noting how this was evidence of her commitment to help her son
through his probation requirements, even though she knew it would not be
easy for her given her busy schedule. Without additional prompting, Lynn
went upstairs to make another request for Anthony to join the session downstairs. After a brief delay, Anthony joined the session.
At first, Anthony appeared agitated about having to participate and
vocalized his opinion about therapy being useless and a waste of time; nothing is wrong with me. Lynn rolled her eyes at this comment and began to
exhibit frustration with his behavior. She was openly hostile toward him and
launched into a number of statements that included content about how useless he was; how he never helps around the house, doesnt go to school,
and is secretive about everything in his life; and how he was a habitual
liar. She ended her comments with the statement that he probably was
going to end up just like his father. Anthony immediately reciprocated her
attacks by turning to her and screaming, Shut up! Lynn appeared visibly
stunned and said nothing while Anthony began to vocalize his complaints
about her, including her lack of support of him, how she was never around,
and her poor choice of boyfriends.
The therapist recognized the need to immediately intervene to disrupt
the escalating conflict. Initially, the therapist interrupted and diverted the
attacking comments by responding to each family members comments before
the other person had a chance to respond. This helped break the sequence of
escalation, which would have led to the conflict becoming unmanageable in
the session. With this family, as with many, disrupting the negativity was not
accomplished in a single interruption. Rather, the therapist had to systematically, contingently, and persistently step into the interactions to disrupt the
hostility as mother and son continued to attack and blame one another. The
relentlessness with which the therapist was required to hang in with the family, diverting; interrupting; making relational connections between family
members behaviors, thoughts, and feelings; and attempting to change the
meaning of their attack on one another, left the therapist with the all-toocommon feeling of being alone in the room.
As the therapist interrupted interactions between Anthony and Lynn,
she began to shift the focus from blame and negativity to relational connection. This started with simple comments such as, You have very clear ideas
about what you need from your mom or Even though you are angry, you
still have not given up trying to have a positive impact on him. The focus
was not on contradicting their statements but rather on expanding them to
aspects of their relationship that were not currently evident in the discussion. For example, the therapist noted how much Lynn based her feelings
of being a good mom on how well Anthony was doing, expanding the focus
13190-11_Ch10_2ndPgs.indd 172
2/8/13 11:16 AM
to include how much she valued being a good mom. Her response was an
emphatic Yes. I want the best for my son. It is killing me to watch him throw
his life away. The therapist immediately observed that Anthony became
much more positive following these statements from his mother and pointed
process by saying to Lynn,
Even though it is painful for you to have less contact with Anthony than
you would like, he does seem to be very connectedor at least tuned
into you. When we started, you were clearly frustrated by his not coming downstairs, and you seemed embarrassed by his statements about
treatment. It was almost like you felt the need to protect me from his
behavior. He immediately showed his connection to you by responding
with all the things you do to frustrate him. Now, when we start talking
about the positive parts of your being a mom, he calms right back down.
Has he always been this connected to your feelings and actions?
The therapist further focused on the familys strengths, making comments such
as, From what I was told, you two do not let things escalate beyond control.
You choose to walk away from each other rather than staying in an argument.
Lynn then acknowledged that this had occurred just the evening before.
As the therapist focused on positive behaviors and on the relationship between mother and son rather than on the content of their complaints
about one another, Lynn and Anthony became less hostile toward each other.
The cessation of attacks allowed the therapist to ask questions about behavioral sequences to gather more information about interaction patterns that
tended to recur and, in particular, to ask about the progression of arguments
between the two. Anthony relayed that he tended to walk away or become
more aggressive with his mother so she would stop questioning his behaviors.
Because it was important to maintain a relational focus, the therapist turned
to Lynn and asked what she did next when Anthony became aggressive. She
reported that she tended to give up and withdraw to her room. Then neither
would speak to the other for a period of time until Lynn reinitiated some level
of conversation a day or two later. Further information was gained in later sessions that Lynn consistently reengaged in conversation with Anthony after a
period of limited contact between the two.
Lynn and Anthony appeared similar in the intensity of their anger
toward one another. The therapist commented on their anger as something
you share in common, and she commented that anger often indicates underlying hurt feelings and suggested that the extremes of anger suggested that
both mother and son were experiencing a lot of pain. Lynn agreed that she
had felt very hurt for a long time in her life, not only with Anthony but in
other relationships, and that she just gives up trying to make those relationships better. This statement from his mother was met with silence from
Anthony, an indication that his combativeness had lessened and that he was
13190-11_Ch10_2ndPgs.indd 173
173
2/8/13 11:16 AM
considering what his mother had said. The therapist recognized that an alliance was developing and that the timing to use reframing might be optimal
to further reduce blaming and negativity regarding the described behaviors
Anthony and Lynn had expressed, so she introduced reframes. To Anthony,
recalling Lynns previously defined complaint of his behaviors of lying and
not talking with her, the therapist said,
When you purposely withhold information about your life from your
mother, such as where you were last night, it angers her. She continues questioning you, and you get even angrier. On one hand, it makes
both of you feel worse, but on the other hand, maybe you dont tell her
everything because you may be worried that some of your behaviors will
disappoint your mother, and if you dont tell her, she wont have to feel
like she is a bad parent.
And to Lynn, the therapist said,

The anger you possess about Anthonys not responding to you seems
to get channeled into your constant complaints to him about his lack
of interest in school or getting a job or the bad group of friends he has.
Behind that I see your fear that he will have to be in the same situation
you are in nowhaving to work multiple jobs to provide for your family.
Although this hard work is very honorable, you dont want to see your
son have to struggle as you have. You want more for him, and by constantly getting on him about his behaviors, you hope this will motivate
him to make some different choices and changes in his life.
Over the course of the session, both Anthony and Lynn became less
defensive and resistant. Anthony vocalized his knowledge that his mother
worked hard for them as a family. Lynn held firm to her complaints about
Anthony but was able to make some positive comments about his behavior
as well, offering a compliment about him being good with his younger sister. After acknowledging and highlighting this positive interaction between
Anthony and Lynn, the therapist ended the initial session, asking them to
meet again in 2 days to follow up quickly on the gains made in the session
and avoid having them fall back into their longstanding pattern of arguing
and exchanges of anger.
The therapist also made a call to the family between the first and second sessions to speak with both Anthony and Lynn and caught them both
at home. Lynn relayed her frustration with Anthony that day as he had not
attended school: I wish he would just do what I say. Why doesnt he get that
it so important to go to school? This was an opportunity for the therapist to
revisit the strength-based relational statements and themes used in first session: that they both worried about each others well-being and continued to
remain committed to finding a different way of working together.
13190-11_Ch10_2ndPgs.indd 174
2/8/13 11:16 AM
Sessions 2 and 3
In the second and third sessions, the therapist worked with the family
to further reduce negativity between Anthony and his mother and to build
hope and increase the bonding between them. To make progress toward these
goals, the therapist used the time between the first and subsequent sessions to
develop additional and better informed reframes and themes. The information
she gathered about Anthonys and Lynns behavioral patterns and relationship
dynamics included the following: Anthonys withholding of information from
his mother and being noncompliant; Lynns not always being there for Anthony,
especially when he was younger; Lynns perceived inability to provide Anthony
with empathy or support when he was in trouble at school or with the law; and
the ongoing anger that both shared with one another. The therapist also decided
to revisit Lynns past history of poor choices in her relationships but would doing
so through a strength-based theme. Two themes were presented to the family in
both the second and third sessions. Theme 1 was presented as follows:
For years, you both have been stuck in a fairly tight pattern with each
otherone in which you, Anthony, may feel you can never do enough
to show your mother you are a competent kid and in which you, Lynn,
continually have to make sure that he is OK. So Lynn, you have been
working very hard at this by questioning each and every step he makes,
being overbearing at times (even when he was 3 years old), and hovering
over his every step with constant correction and discipline but maybe
focusing only on the negative behavior he has done. Part of it is about
yourself and your worry that because of the choices you made in your life,
you feared Anthony would suffer, so you wanted always to protect him
from those same choices. It is almost as if, by being so dismissive of him,
Anthony would learn to do things on his own, and if he learned not to
rely on you, he would learn to be strong and independent.
Note that this extensive theme contained affirmations of negative behaviors

but suggested that the intent may have been positive, perhaps even noble, in
terms of protecting Anthony while acknowledging Lynns previous mistakes.
Theme 2 was presented as follows:
Anthony, you have gotten to the place where you no longer want to be
around your mother, and this has been going on since you were young.
You have fought with her since then as well, challenging her with your
defiance. Maybe you were and are just a difficult kid and not caring for
your mom [acknowledgment of Anthonys possible negative qualities],
but the other side to look at is that you help your mom. And the fights
and arguments were also about trying to strengthen and teach your mom
to fight back and be strong in her relationships because you had seen how
much she struggled in her own life to be strong and stand up for herself.
13190-11_Ch10_2ndPgs.indd 175
175
2/8/13 11:16 AM
By the end of the third session, Anthony and Lynn had significantly
decreased the complaints and negative statements toward one another. They
expressed feeling more hopeful and positive about their relationship, shared
more openly during sessions, and reported positive interactions they had with
one another in between sessions.
Relational Assessment Phase
During the first three sessions, the therapist directly observed the interactions between Anthony and Lynn and elicited information about the typical
pattern of interaction and behaviors, particularly those sequences surrounding behavior problems such as truancy, curfew violations, and arguments in
the home. This information served as the basis for analyzing the patterns
of interactions, behaviors, emotions, and cognitions to determine the core
motivating factors or functions of each of them with the other.
One of the primary patterns identified was that when Anthony and
Lynn were in conflict or when there was an issue of concern that Lynn had
about Anthony, she would spend considerable energy and efforts to question Anthony, initiate discussions with him, and reach out to him in any
way she could. This would result in Anthony becoming annoyed, which
brought on a brief period of intense conflict that was rapidly followed by
his leaving, either going to his bedroom or leaving the home altogether, for
a significant period of time. During his absences, Lynn would send him text
messages on his cell phone, and Anthony would not respond. Lynn would
then go to work or begin concentrating on her daughters needs but would
harbor feelings of anger toward Anthony. Anthony, for his part, would continue about his day and be more focused on himself and his friends than
his mother. However, when Anthony observed times when Lynn expressed
her feelings of sadness or when she commented on his positive behaviors,
Anthony would respond to Lynn. On an average day, Anthony would spend
much of his time with friends or in his room while Lynn was working. They
would talk briefly when she returned home between shifts, and these discussions, most of the time, would end up in escalations and arguments.
On the basis of the information about patterns of interaction the therapist
obtained, she identified Anthony as having a function of distance/autonomy
in his relationship with his mother and Lynn as midpointing in her relationship with Anthony:
77
77
Anthony to Mom distance/autonomy

Mom to Anthony midpointing
The hierarchy was assessed to be a symmetrical one, in which both Anthony

and Lynn shared resources and had influence in the relationship and the
13190-11_Ch10_2ndPgs.indd 176
2/8/13 11:16 AM
behaviors of each other. This symmetry was not typically expressed in overtly
disrespectful ways. In fact, Anthony respected his mother and responded well
to her nurturance. However, neither Anthony nor Lynn was particularly
effective in influencing one anothers behaviors.
Having achieved the goals of the Motivation Phase and having completed
a relational assessment, the therapist planned to initiate behavior change activities in the fourth session. To prepare for the Behavior Change Phase, the therapist
sketched out a plan to address problems at several levels. The first level involved
eliminating the individual referral problems of the adolescent (e.g., truancy,
theft, noncompliance, defiance toward authority). The second level involved
developing and implementing interventions to help Anthony and Lynn learn
alternative and adaptive strategies for getting space (instead of withdrawal) and
expressing assertiveness (instead of hostility). At this level, interventions were
designed to improve family communication and conflict resolution. These relational targets were viewed as essential for reducing risk associated with a negative family climate leading to a rejection of mother and an increase in time spent
with deviant peers. However, improving these interactions was also necessary
to directly reduce Anthonys referral behaviors because they created a relational
context and provided concrete skills for Anthony and Lynn, such as decision
making, anger management, and behavioral contracting.
Session 4: Communication Training and Conflict Management
The first step in the Behavior Change Phase was to directly address the
communication patterns that were interfering with adaptive behaviors. As
is done with many families seen in FFT, the therapist started with a communication training task that focused on building basic communication skills,
such as brevity and specificity in their questions, statements, and requests
and active listening (i.e., reflective statements, appropriate verbal and nonverbal responses). Because Anthony and Lynn were both quite articulate
and interpersonally savvy, most of this exercise was devoted to helping them
use a few simple techniques that would disrupt highly conflicted exchanges.
Thus, in this session, the therapist also introduced additional conflict management skills to further reduce the escalation of the conflict by building and
practicing skills that helped Anthony and Lynn resolve conflicts. These skills
included staying on one topic at a time, avoiding negative attacks or statements about each other, refraining from bringing up past failures or history of
negative behaviors, and using active listening skills.
13190-11_Ch10_2ndPgs.indd 177
177
2/8/13 11:16 AM
To facilitate these tasks in the session, the therapist started by providing

a rationale for these activities. This rationale included a theme of protection
that the therapist believed would resonate with both Anthony and Lynne:
You both work very hard not to further stress the relationship and protect
one another by withdrawing from the conflicts. I want to teach you some
new skills that will help you talk more positively with one another and
about important issues without it escalating into a major argument. I
recognize that you both work very hard to support one another but have
done so in ways in the past that have caused further stress in your relationship. I would like to offer you both new ways to support each other.
It should be noted that although the therapist may use the themes from earlier sessions as part of the rationale for behavior change, the themes that are
used do not have to line up with the relational functions for the case. For
example, the therapist may use a theme of nurturance and support in the
family but continue to maintain relational distance or midpointing.
Anthony and Lynn were very hesitant at first, but because their alliances
with therapist were both positive and balanced, they stated their reluctance
in session. Anthony was the most vocal with his concerns, even resorting
back to blaming statements of Lynnfor example, She will never try something different. The therapist quickly acknowledged Anthonys concerns
and noted her expectation that both he and Lynn would have reservations
about trying something different for fear it may not work (matching). With
that, the communication skills of brevity, specificity, and active listening
were introduced to Anthony and Lynn by the therapist. She provided them
with a handout that described the communication skills and reviewed this
during the session introducing the skill or task. The handout also provided a
technical aid to Anthony and Lynn to review outside of sessions when they
practiced the skills. It was helpful for them to begin practicing these skills
immediately in the session as the therapist wanted them to experience some
level of success in trying them out (skill practice and rehearsal). Mother and
son seemed awkward at first. Lynn, in particular, had difficulty being brief.
The therapist asked her to state a concern she had with Anthony in two
sentences or less and she did so, smiling slightly. For his part, Anthony smiled
when he reflected to Lynn what he had heard her say. The therapist commented that this was one of the first times since beginning therapy that they
both seemed to be enjoying each others company, even though practicing
these skills was challenging (strength-based relational statements).
After two more attempts at practice of the newly introduced skills, the
therapist offered feedback to Anthony and Lynn (review and provide feedback). Anthony was given significant praise for his patience with his mother
and for not looking as though he was getting frustrated with the concerns she
had. Lynn was also given praise for her attempts to reduce her overexplaining
13190-11_Ch10_2ndPgs.indd 178
2/8/13 11:16 AM
of the concerns and keeping the statements centered on how she felt about
the issue versus blaming or attacking Anthony. Both needed to continue to
use more brevity and watch the congruence between what they said and their
body language, especially Anthony, as he had a tendency to roll his eyes at
Lynn during the practice.
After modeling and facilitating practicing communication and conflict
management skills in the session, Anthony and Lynn were given homework
to practice these skills in their daily lives. However, to maintain the relational
functions of Anthonys distance/autonomy with Lynn and Lynns midpointing
with Anthony, time limits were set on the interactions between them. They
were asked to meet daily to discuss any issue of concern Lynn had, but for only
short periods of 10 to 15 minutes at a time. If the issue could not be resolved
using the learned skills in that time, they were instructed to take a time-out
until the next day. This strategy helped maintain the sense of autonomy needed
by Anthony while also giving Lynn some measure of contact/closeness and
relational influence with Anthony. Positive time together was also incorporated as a reward for Lynn if they were successful in using learned skills, therefore meeting the contact/closeness need of her midpointing function with
Anthony. For example, the plan included dinner together two times per week
without the technological distractions of cell phones, televisions, and video
games. The therapist found it unnecessary to focus further on the parentchild
hierarchy because Andrew and his mother were seemingly equally influenced
by the others actions and did not exhibit behaviors of a power struggle.
Session 5: Review and Anger Management
In Session 5, the therapist maintained her focus on within-family behaviors and interactions but extended the focus to include concrete anger management skills that were conceptualized to be directly relevant not only for
improving family functioning but also for reducing Anthonys behavior problems outside of the home. With respect to the latter, for example, anger management skills were seen to be protective for his fighting at school as well as
for the assertiveness needed to resist peer influences.
The session started with a review of the homework from the prior week.
Both Anthony and Lynn said that they did not practice as much as they had
initially planned, so the first part of the review involved helping them identify
the barriers that kept them from practicing as well as the times or conditions
that made it easier to do the homework. From this discussion, they were able to
identify times or situations that were optimal to meet and, perhaps even more
important, times when one or both of them needed space (e.g., immediately
after Lynn returned home from work). The review also involved examining
what went well in their discussions, how they felt, and what they were doing
13190-11_Ch10_2ndPgs.indd 179
179
2/8/13 11:16 AM
that contributed to (or interfered with) success. Facilitating the articulation of

these features helped them own or lock in these new behaviors. Throughout this
discussion, the therapist encouraged them to continue practicing and rehearsing
these skills with one another rather than simply reporting back to the therapist.
Anthony and Lynn both had practiced at home and had some difficulty
sticking with the active listening. However, both remained encouraged and
reported to the therapist that they had only one major conflict that week. The
therapist reintroduced the conflict management skills in this session and followed
a similar format of providing the rationale, rehearsal, and feedback. Anthony
and Lynn participated well in the rehearsal, and this allowed them to begin to
discuss and resolve simple topics of concern, such as his school attendance.
The therapist also addressed anger management to provide them with
additional skills for dealing with intense emotions. This involved teaching
Anthony and Lynn to recognize when they were feeling angry and to respond
to their feelings using three basic anger management steps: (a) calm down,
(b)analyze the situation, and (c) think about options. The therapist presented
the goal of anger management as learning to communicate angry feelings in a
way that doesnt hurt yourself and doesnt hurt other people. This will help get
your needs met without having to push people around and without you feeling
pushed around by others. The therapist explained that anger is caused not by
trigger events alone but by thoughts or beliefs about those events:
Here are some ways to think about anger triggers so you can increase
your ability to control your behavior. The first thing to do is calm down.
As long as you keep cool, you will be in control of the situation. Some
phrases to help you cool off in a crisis might be slow down, cool it,
stop and think, count to 10, or take a deep breath.
After exploring with Anthony and Lynn what phrases they each might use as
self-talk, the therapist guided them to think about the situation (e.g., What
gets me angry? Is this really a personal attack or insult? What will be the
consequences if I act aggressively? What good could come out of controlling
my anger?). Then the therapist helped them review options in terms of using
anger as a signal that it is time to do some problem solving (e.g., What can I
do?). The therapist discussed how relaxation, communication skills, a timeout, or other coping skills might be useful for Anthony and Lynn and they
formulated a plan to try out before the next session.
Sessions 6 to 8: Functional Analysis of Behavior, Decision Making,
andContracting
The improvements in communication and conflict resolution skills in
the prior sessions provided a context to focus on building skills that were
13190-11_Ch10_2ndPgs.indd 180
2/8/13 11:16 AM
more directly related to truancy, fighting, and other behavioral problems.

Thus, in the sixth session, the therapist shifted the focus to helping them
address the referral problems directly. Given the specific focus on Anthony,
the therapist framed this shift in focus (rationale) to meet his goals of getting
off probation and getting people off his back.
The first new task introduced in this session was a functional analysis
of Anthonys truant behaviors. Truancy was picked by Anthony because
he said this was the behavior that he fought the most with his mom about.
The therapist provided a functional analysis handout presenting the links
between antecedents, behaviors, and consequences and helped Anthony and
his mom engage in a conversation about the behavioral, emotional, cognitive, and environmental antecedents and consequences of his truant behaviors. Throughout this task, the therapist coached them and facilitated their
interactions to build skills in identifying these linkages.
At the conclusion of this task, Anthony and Lynn had developed a
thorough matrix that identified several key antecedents of truancy (or attendance) as well as both the negative (e.g., suspension, violation of parole, and
failure in school, which was linked to embarrassment) and positive (e.g.,
hanging out with friends) consequences of his behavior. They were given
homework to conduct additional functional analyses of the antecedents and
consequences associated with missing his curfew. The therapist also asked
Lynn to conduct her own functional analysis of her positive and negative
reactions to Anthony when he missed curfew. The intent was to help her to
break down these sequences to expand her behavioral skills in dealing with
Anthonys misbehavior as well as to reinforce those behaviors that she was
already engaging in that resulted in positive responses from Anthony.
In the seventh session, the therapist used the functional analysis to target specific decisions that both Anthony and Lynn made that contributed to
adaptive (e.g., attendance) or maladaptive (e.g., attacking, fighting) behaviors. Specifically, the therapist introduced a decision-making skills exercise
to break down the cognitive and behavior process involved in the truancy.
The therapist helped Anthony and his mother discuss the consequences of
his actions and explore alternatives to his truant behaviors that might still
achieve some of the same positive outcomes (e.g., time with friends).
In the eighth session, the therapist helped Anthony and Lynn develop a
behavioral contract surrounding his truant behaviors. The contract included
specific expectations regarding his attendance as well as consequences and
rewards for his conforming to these expectations. Given their hierarchical
symmetry, Anthony was integrally involved in defining the parameters of all
aspects of this contract. The rewards for attendance included increased time
spent with peers after school (which had previously been restricted because
of his misbehaviors) as well as an extended curfew on weekends. To satisfy
13190-11_Ch10_2ndPgs.indd 181
181
2/8/13 11:16 AM
Lynns need for midpointing, the contract was clear about her communication expectations while Anthony was spending this additional time with
peers. For example, the contract stipulated that Anthony had to inform Lynn
about where he was going and whom he was with and that he had to text her
at least once per hour. This met his need for relational distance and provided
him with a valued reward, and it was also consistent with Lynns midpointing
relational function.
Generalization Phase and Termination
The goals for the Generalization Phase were to aid the family in extending and generalizing their learned skills to other relationships outside their
immediate family, maintaining new and positive behaviors by planning for
and responding to relapses in negative behaviors, and supporting the maintenance of positive changes with linkage to resources and other services to
address remaining risk factors of the family and individuals in the family. The
therapists planning for generalization focused on three areas: (a) generalizing
communication, conflict resolution, anger management, and decision-making
skills to other relationships in Anthonys and Lynns lives; (b) developing steps
to get Anthony to attend school regularly and remain in good standing; and
(c) anticipating future barriers to prevent the reemergence of negative behaviors and maintain the positive behaviors in their relationship.
Session 9: Extending Skills to Peers
In the ninth session, the therapist focused on generalizing new communication, conflict management, and decision-making skills to relationships
beyond the family. Given the history of fighting at school, the therapist started
by helping Anthony and Lynn discuss the antecedents and consequences of
Anthonys behaviors and develop alternatives and plans for addressing these
situations in the future.
The therapist also introduced plans for communicating with school personnel about the behavioral contracts that were put in place with Anthony
regarding his truant behavior. Specifically, the therapist coached them on
how to engage and discuss this issue with the school counselor to ensure
that everyone had the same expectations for Anthony. During this process,
the therapist directly addressed Lynns feelings of embarrassment and shame,
which were interfering with her contacting the school to reestablish positive
communication and feedback processes. The therapist and Lynn role-played
this conversation, and Lynn was given the homework assignment of contacting the school prior to the next session.
13190-11_Ch10_2ndPgs.indd 182
2/8/13 11:16 AM
Session 10: Dealing With Relapse

Session 10 started with Lynn raising concerns about her interactions
with her daughter, who to date had not been a focus of treatment. On the
basis of the skills Lynn had already developed with respect to Anthony, the
therapist rehearsed with Lynn specificity in her requests of her daughter.
Anthony also added new topics, specifically, the impatience and anxiety that
he experienced when asked questions by teachers at school. The therapist
had Anthony rehearse his active listening responses to teachers when they
would call him out in class or question his behavior. Because his school performance had been reported by the school as OK, the therapist did not undertake specific studying skills or remedial actions.
After these brief discussions, however, Anthony and Lynn started
expressing intense anger at one another again. Hours before, they had been
involved in a very heated argument that resulted in Anthony leaving the
home without letting Lynn know where he was going. The therapist used
this event as an opportunity to discuss relapse, as this was indeed an example
of the family reverting to their earlier dysfunctional interaction patterns.
Lynn admitted that she had escalated the argument and became very negative toward Anthony, calling him names and being demeaning. Anthony
said he had defended himself by reciprocating the name calling and character
attacks. The therapist pointed out where the lapse had occurred and what
triggers had caused the conflict to escalatenamely, Lynn had been stressed
from work that day, which left her feeling depressed about their financial
situation. She had then confronted Anthony about him not helping the family by trying to get a part-time job. The therapist had them both review
their functional analyses to remember the antecedents of conflict with each
other. Both agreed that when these situations occurred, they would attempt
to refrain from bringing up concerns they had with one another that day but
hold off until a later time.
Session 11: Anticipation of Future Barriers
The therapist asked Lynn and Anthony to identify situations that might
increase the risk of Anthony reverting to his referral behaviors or that might
lead to an increase in family conflict. Two areas emerged: Anthony getting a
job and Anthony getting a drivers license. The therapist facilitated a discussion about each of these areas to identify the associated risks and develop
a behavioral plan. Both agreed about the fundamentals. They both wanted
Anthony to get a job and a license, but Lynn was worried that this would give
him too much freedom or, stated differently, too many opportunities to go
back to the way things were before. After a brief discussion, Anthony proposed
13190-11_Ch10_2ndPgs.indd 183
183
2/8/13 11:16 AM
that they develop a behavioral contract for these two areas that specified each
of their responsibilities.
Session 12: Termination
In the final session, the therapist began by reviewing the skills that
Anthony and Lynn had learned and demonstrated. Lynn was appreciative and,
beaming at her son, said, I am proud of him, and of us....It hasnt been
easy....It still isnt at times, but we keep trying. Anthony had set a personal
record (at least for the last 2 years) of school attendance, having attended for
2 months without a single missed day or late arrival. Anthony relayed that he
was anxious for spring break as he was going to focus on looking for a weekend
job. The therapist remarked, Lynn, it looks like he heard you. Did you let him
know directly how much you appreciate this? Lynn commented, Well, I dont
see him very often. The therapist responded by saying, I knowhow about
just texting him or leaving a note? and Lynn replied, Sure, I can do that. The
therapist turned to Anthony and asked, So do you need a big hug from Mom,
or would a note do? Anthony turned to Lynn and said, seemingly sarcastically
but in an appropriate way, Oh, please, write a note! Everyone laughed.
The family reviewed the challenges they faced; Anthony still needed to
complete community service hours but had been working with his probation
counselor on a plan to complete them and expressed his intent to do so. Lynn
was laid off from one of her jobs, so they were going to be financially strapped
for a time, but she was happy to report this did not cause her to retreat into
her usual sadness.
The therapist had asked Anthonys probation counselor to attend the session by phone. Anthony and Lynn were required to maintain this relationship
until Anthony had completed all his sanctions, so this provided an opportunity
for the probation counselor to hear directly the progress made by both and
have an understanding of their plan to maintain positive skills and behaviors.
The counselor reported, I still need to see it to believe it, but this is the best
report weve seen for 2 years. Anthony, youve done well. Anthony shrugged
his shoulders but looked down and smiled. The therapist commented on this to
the counselor, who responded, Anthony, you just keep in touch the way you
are supposed to. I want to sign that release form and get you out of my hair.
Everyone, including the therapist, experienced this as a positive response, and
the exchange had a light tone. The therapist thanked the counselor and ended
the session by saying, I hope youll feel free to call me if you want me to do
anything else, but Im ready to get them out of my hair also...and vice versa,
I think. Anthony responded, with a smile, You got it.
13190-11_Ch10_2ndPgs.indd 184
2/8/13 11:16 AM
III
Administering and
Extending FFT
13190-12_Ch11_2ndPgs.indd 185
2/8/13 11:15 AM
13190-12_Ch11_2ndPgs.indd 186
2/8/13 11:15 AM
11
Features of Successful
FFT Implementation
We have described the research evidence, clinical theories, and specific

interventions that serve as the foundation for the Functional Family Therapy
(FFT) model and provide therapists with the tools and conceptual grounding
that are necessary to implement FFT. The implementation of family therapy,
however, does not occur in a vacuum. Many contextual factors can serve to
facilitate or hinder the implementation of FFT. In this chapter, we describe
some of these features and provide specific recommendations that have implications for therapists, agencies, and larger systems.
DOI: 10.1037/14139-012
187
13190-12_Ch11_2ndPgs.indd 187
2/8/13 11:15 AM
Influence of Context on Clinical

Processes and Outcomes
As noted earlier in this book, research has provided strong support for the
efficacy and effectiveness of comprehensive family and ecologically based interventions, such as FFT, with drug-using, delinquent adolescents. This evidence
has included positive effects in randomized trials, qualitative studies, and metaanalyses (e.g., Curtis, Ronan, & Borduin, 2004; Waldron & Turner, 2008).
However, the large effects observed in controlled research studies are often hard
to achieve in real-world settings (Curtis et al., 2004), and research is beginning
to emerge to identify factors associated with these reductions in the potency
of evidence-based programs when they are disseminated into the community
(Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Glasgow, Lichtenstein, &
Marcus, 2003; La Greca, Silverman, & Lochman, 2009; H. A. Liddle, Rowe,
Dakof, Ungaro, & Henderson, 2004; Sholomskas, Syracuse, Ball, Rounsaville,
& Carroll, 2005; Simpson & Flynn, 2007). For example, Glasgow, Vogt, and
Boles (1999) stressed that high-quality implementation is a requisite component for achieving the desired program outcomes. Like others, they noted that
closer adherence to core treatment model components was linked to more
positive outcomes (Abbott et al., 1998; Botvin, Malgady, Griffin, Scherer, &
Epstein, 1998; Embry & Biglan, 2008; Henggeler, Melton, Brondino, Scherer,
& Hanley, 1997). Rogers (2003) and others (e.g., Mihalic & Irwin, 2003) also
have emphasized the importance of clinician training, adherence to treatment
goals, and therapists competent delivery of model elements.
Treatment fidelity is challenged in real-world settings in many ways.
For example, therapists in real-world settings often carry large caseloads and
have multiple roles within their agency. Therefore, there is often less time to
devote to training and ongoing supervision and monitoring for therapists in
community agencies. Despite these concerns, studies have demonstrated that
treatments can be transported to the community with high fidelity to core
treatment philosophies and techniques (Henggeler, Clingempeel, Brondino,
& Pickrel, 2002; H. A. Liddle et al., 2006).
In part, the quality of implementation in real-world settings is influenced by infrastructure supports and organizational variables. For example,
Glasgow et al. (1999, 2003) suggested that during implementation, clinicians
are likely to be influenced by aspects of the organization and may be more
successful in their implementation efforts in an environment that is more
supportive of the treatment program. Similarly, Fixsen et al. (2005), in their
comprehensive review of the literature on technology transfer in the areas
of mental health and education, identified core components that are prerequisites for successful implementation, including continuous supervision
and continuous performance evaluation via supervision, adherence checks,
13190-12_Ch11_2ndPgs.indd 188
2/8/13 11:15 AM
and feedback. Also, Simpson (2004; Simpson & Flynn, 2007) highlighted
training and supervision as critical elements that contribute to intervention
effectiveness.
Research also shows that organizational readiness acts as the foundation for the successful implementation of EBTs (Fuller et al., 2007; Saldana,
Chapman, Henggeler, & Rowland, 2007). According to the framework
described by Simpson and Flynn (2007), program climate is considered to be
critically important during the implementation phase. Research on aspects
of program climate supports this position (Joe, Broome, Simpson, & RowanSzal, 2007). In the sections below, we provide information about program
characteristics we have found to be favorable to the implementation of FFT
in community settings. Consistent with our fundamental philosophy about
using research to inform practice, the recommendations in this section are in
part influenced by the extant research on the organization variables described
above. However, these recommendations are also based on our extensive
experience disseminating FFT with more than 250 agencies and thousands
of therapists and families.
Organizational Characteristics
Favorable to Implementation
FFT has been successfully disseminated in many settings, including
juvenile justice, mental health, substance use, child welfare, and schools.
Each of these settings presents unique challenges at multiple levels, including
variations in the types of youth and families that are referred (delinquency,
mental health, drug use, trauma, abuse or neglect), philosophies about the
conditions necessary to achieve change (punitive vs. supportive, individual
vs. relational), or commitment to implementing evidence-based practices
(open vs. defensive). It is therefore not surprising that successful implementation requires a careful tailoring of training, supervision, and ongoing
monitoring to meet the needs of each individual system. However, we have
found that the processes involved in achieving successful outcomes actually
are consistent across settings. Thus, although the specific details or content
involved varies by systems or agencies, the larger patterns are predictable.
Agency and Funding Source Buy In
According to Fixsen et al. (2005),
Without hospitable leadership and organizational structures, core implementation components cannot be installed and maintained. Without
features of successful fft implementation
13190-12_Ch11_2ndPgs.indd 189
189
2/8/13 11:15 AM
adequate pay, skillful evidence-based practitioners will be hard to find

and keep and programs will falter. Like gravity, organizational and external influence variables seem to be omnipresent and influential at all levels
of implementation. (p. 58)
Many FFT therapists work within organizations or systems, and these systems can have a profound influence, directly or indirectly, on the day-to-day
practice with youth and families. Respecting the influence of these larger
systems and working in coordination with administration are therefore paramount goals of successful implementation. In fact, any dissemination process
to an organization or system begins with information sharing and an open
dialogue between agency administration (and relevant staff and community
stakeholders) and trainers. Within the context of this dialogue, the parameters and expectations about costs, staffing, resources, training, supervision,
ongoing monitoring, communication plans, and so forth are reviewed and
tailored to the unique structures of agencies and systems. In FFT, there are
core principles that are ubiquitous across contexts, such as the clinical content of the model, the delivery of information via training workshops, and
weekly consultation and supervision; however, there is also flexibility in the
process to ensure that training is most effective for the system, therapists, and,
ultimately, families that are served by an agency.
Building agency commitment and buy in to a relational approach is an
essential part of the initial startup process. Even in ideal circumstances, when
agency leadership values evidenced-based practice and believes that working
with families is critical to helping youth in need of services, the expectations that members of the system have can become a major obstacle to the
implementation of FFT when there is a discrepancy between the agencys
standard operating procedures and the recommended course of action in FFT.
For example, when working with child welfare systems, a primary focus often
is centered on the safety and well-being of children and youth in the family.
Unfortunately, this safety-first focus often undermines the treatment process
and leads to immediate negative outcomes for youth and families, most notably the removal of individuals from the home. Although these interventions
may remove immediate risk (e.g., abuse, neglect), they typically have no effect
on creating changes within the family that are sustained over time, and youth
and families remain at risk. Moreover, these interventions often lead to ruptures in the therapeutic relationship that further increase family members risk
for dropout from treatment.
By contrast, FFT therapists work to ensure that the same safety goals are
met, but the focus is on creating lasting change in the family, which can lead
to qualitative differences in how safety plans are implemented at the agency.
For example, in early sessions with high-risk cases, the frequency of sessions
is increased to ensure that immediate motivational goals are met and that the
13190-12_Ch11_2ndPgs.indd 190
2/8/13 11:15 AM
specific behavior change plans can be initiated as quickly as possible. In these

circumstances, it is common for therapists to conduct two or three sessions
per week with families for the first 2 weeks of treatment. These types of differences in foci and clinical decision making can cause conflict in the relationships at multiple levels: between FFT therapists and child welfare workers in
the system, between FFT therapists and FFT supervisors, and between agency
administrators and FFT trainers and supervisors. Anticipating and addressing
such discrepancies at the outset through open communication and dialogue
are essential for successful implementation.
Maintaining dialogue with administration over the course of implementation is a key component of adoption and maintenance of FFT. Ultimately,
implementing an evidence-based model like FFT requires that agencies carefully examine virtually all of their internal standard operating procedures,
from hiring of staff, to clinical practices and policies (e.g., work hours), to
referral processes. All of this requires administrative oversight and resources
to prepare the site and staff for starting training and sustaining the model
over time.
Again, even under the most favorable conditions, all of the potential
pitfalls and challenges cannot be anticipated or addressed during the startup
process. It is not until training and implementation begin that many of the
challenges emerge. From an FFT model perspective, working through these
challenges in a context of professional collaboration is just as important as the
training and supervision process. This requires a careful review of the nature
of challenges (e.g., appropriateness of referrals, intake processes, staffing) and
development of quality improvement plans that are tailored to the developmental phase of the FFT team. It is through this collaborative process that we
work to create an agency context in which therapists and other staff embrace
an FFT-based (family-focused) method of working with youth.
Time and Flexibility
There are numerous ways in which organizational context affects the
quality of implementation of FFT. For example, providing time for therapists
to participate in training and weekly supervision is critically related to therapist development and model fidelity. Therapists who have time to review prior
sessions and plan for the next session learn the FFT model more rapidly and
are able to deliver services with higher fidelity than do therapists who have less
time to participate in these training and consultation activities. Also, therapists
who have reasonable caseloads (approximately 1012 for a full-time therapist,
depending on the nature of the practice settinge.g., office vs. home based,
prevention vs. treatment) are able to more effectively implement the model.
These conditions, in turn, translate into better outcomes at lower cost.
13190-12_Ch11_2ndPgs.indd 191
191
2/8/13 11:15 AM
Successful implementation also requires therapist and agency flexibility

around when and where services are provided. Family members often have
multiple roles or responsibilities (e.g., work, school) that make it unlikely
that they will be able to attend therapy sessions during classic workday hours.
Providing flexible evening and weekend alternatives is an essential part of
working with families. Similarly, many families have difficulties organizing
themselves to come to treatment or securing transportation to come to an
office. Agencies and therapists who provide flexible alternatives that match
the needs of the families they serve have better engagement and retention
rates and clinical outcomes than do agencies that expect that all families will
come to the office. Flexibility can lead to sessions being conducted in homes,
schools, parks, and so forth. Our philosophy is that location should not stand
in the way of youth and family access to evidence-based services.
Therapist Variables
In four decades of providing FFT to families in multiple settings, we
have learned that FFT can be implemented by therapists with diverse professional backgrounds, life experiences, and cultural as well as gender identification. The majority of FFT providers have tended to be masters level, with
degrees in mental health, family therapy, social work, and so forth. However,
the model has also been successfully implemented by PhD-level social workers, psychiatrists, and psychologists, as well as bachelors-level counselors and
paraprofessionals. FFT also has been and is provided successfully by therapists
who identify themselves as female, male, or diverse members of the lesbian,
gay, bisexual, and transgender community. Providers have ranged in age from
their early 20s to late 70s.
Although this diversity makes it difficult to identify what therapist variables might be most predictive of effective implementation, we have found
that several overarching variables are important to consider when selecting
therapists for FFT: (a) a commitment to and belief in working with families
and systems as a critical part of effective treatment of youth problem behaviors;
(b) a willingness and openness to learn and try out new behaviors; (c) flexibility and availability in when and where services are provided; and (d) a mix of
interpersonal and structuring skills, as evidenced by their quality and clarity
of communication in interviews, mock sessions, or examples of clinical work
with families.
Therapy Process Variables
After the initial selection of therapists, the most important predictor of
quality of implementation is practice, practice, practice! Therapists will not
13190-12_Ch11_2ndPgs.indd 192
2/8/13 11:15 AM
learn the model unless they have ample opportunities to work with families.
To ensure the rapid adoption of FFT during training and the maintenance of
FFT over time, we recommend that therapists maintain at least five active
cases at all times. Our experiences suggest that dedicated FFT therapists are
much better able to implement the FFT model with higher fidelity. However,
in many contexts, therapists have many roles and responsibilities and provide
a range of services to youth. These therapists are also able to implement FFT
with high fidelity when they have sufficient cases and time to participate in
supervision or consultation and planning for future sessions.
At the process level, we have found that a number of indicators are
associated with successful outcomes in community agencies. For example,
high initial responsiveness appears to be related to long-term recidivism and
rearrest rates. Responsiveness includes time between the initial referral and
the first and subsequent contacts (e.g., first session) with the family. The phrase
strike while the iron is hot seems appropriate for organizing FFT services:
The more rapidly contacts are made with the family, the more likely families
are to engage and complete the course of treatment. In addition, tailoring initial sessions to the level of risk and protective factors of the family when they
enter treatment is also critically related to the successful completion of treatment. As noted above, this may include scheduling multiple sessions during
the first 10 days after the initial referral for high-risk cases. Such intensity of
clinical services is one way that FFT is able to address issues of safety while
simultaneously creating a context that is conducive for achieving long-term
changes in the family system.
Regularity or density of services is also critically related to outcomes
as the potency of treatment is diminished when there are long gaps between
sessions and it takes 8 months, rather than 4 to 5 months, to deliver these sessions. Time between sessions results in a loss of clinical momentum, and it is
often necessary to cycle back to motivation or early behavior change strategies.
Therapists who are able to engage in frequent contacts with family members
between sessions are able to keep the family actively involved in the treatment
process and, as a result, turn over a larger number of families with greater success over the course of a year. Regular tracking of the number of contacts,
sessions, length of treatment, time to initial contact, and so forth is a valuable
tool for therapists and the agency because it helps provide a justification for
keeping caseloads at a manageable level and yields evidence administrators
can use to sustain or obtain funding for FFT services.
All of these features are relevant only insofar as they lead to model
fidelity. Youth and families do not benefit from interventions they do not
receive! And the impact of any intervention is weakened when the quality
of implementation is poor. Training and supervision provide a context for
providing feedback, direction, and support for therapists to help ensure that
13190-12_Ch11_2ndPgs.indd 193
193
2/8/13 11:15 AM
FFT is implemented with the highest quality (see Chapter 12, this volume).
The effectiveness of training and supervision on everyday practice, however,
is also heavily determined by therapists openness to learning new information and willingness to try out new procedures and strategies in the sessions
with families. The learning process can be frustrating and anxiety provoking. For experienced therapists who undertake the journey to learn FFT, it
is a natural part of the training process to drift back toward their standard
practices (pre-FFT), particularly with difficult cases. For novice therapists,
feelings of hopelessness or ineffectiveness can be common. However, learning a complex model like FFT takes practice. Patience, a thick skin, and a
supportive supervision and organizational context serve as the foundation for
building fidelity over time.
Interface With Community Systems and Stakeholders
The interface between therapist and agency and the larger community
systems or stakeholders is another important feature that contributes to successful implementation and positive clinical outcomes. The relationship to
larger systems has implications at many levels, including funding, appropriateness and number of referrals, disruptions of the treatment process, and
integration of services. With respect to referrals, for example, collaborating
with other systems to develop screening processes and tools can lead to substantial improvements in the efficiency of referral processes and can ensure
not only that appropriate youth and families are referred to the agency but
also that they are referred in a timely and efficient manner. Working together
with community systems, therapists, and agencies can minimize the dangers
of overscreening cases (i.e., applying numerous rule-out criteria, based on
agency tradition, that are neither required nor appropriate for FFT), a process
that often results in an insufficient number of referrals for provider therapists.
Insufficient referrals lead to issues of underutilization for agencies, reductions
in model fidelity for therapists, and implications for the agencys meeting
outcome expectations for contracts around number of youth served, which
can lead to a loss of funding dollars for youth and family services.
Ongoing communication with the appropriate community stakeholders
is a necessary part of the FFT implementation process. Some agencies have
dedicated staff members who function in liaison roles with external systems.
Many agencies that serve youth from the juvenile justice system have a staff
representative with an office or space in the juvenile court to establish an
ongoing presence that is useful for generating referrals and supporting the
treatment process. With respect to the latter, for example, this liaison may
be helpful in facilitating clinically informed disposition outcomes when a
13190-12_Ch11_2ndPgs.indd 194
2/8/13 11:15 AM
youth has violated probation, failed a urine screen, or otherwise come to the
attention of the justice system again. Similar agency liaisons can be useful for
working with schools, child welfare, residential facilities, local or state agencies (family services, mental health, alcohol and drugs), and others.
Irrespective of whether an agency provides dedicated staff or whether the
responsibility falls on the shoulders of FFT therapists (or FFT teams), developing and nurturing relationships with community systems and stakeholders
require careful planning and time. Attending a single meeting with a community agency or stakeholder typically does not lead to any lasting change.
Regularity and consistency in communication are essential. Individuals in
external systems are typically overwhelmed with multiple responsibilities and
tasks; for example, probation officers may have more than 100 youth on a
caseload. A therapist or agency that is out of their sight (so to speak) will
quickly fade out of their minds.
Therefore, it is vitally important to establish a mechanism that gives therapists access to key players in the system. Keep in mind, however, that this is not
a one-way street. Therapists should try to figure out how they or their agency
can help address key concerns these players have. This may be as simple as
filling an important treatment need for a segment of youth or families. Or
it may involve conducting presentations or trainings that count toward professional requirements for licensing. Approaching systems like the school
system with this quid pro quo perspective can be highly effective in meeting
both agencies needs and the needs of the external system.
A first step in building effective working relationships with community
stakeholders involves providing a rationale or education about the FFT model
or way of working. This is not simply providing information about FFT; rather,
this involves tailoring the goals of FFT to the specific needs of each system.
For juvenile justice providers, the initial conversation must include a focus on
how FFT directly addresses delinquent behaviors and concrete details about
expectations of youth, family members, and communication with probation
officers. For school systems, a focus on addressing truancy or conduct issues
may be represented in the development of coordinated behavioral and communication plans with teachers or school counselors. In either instance, the
notion is to match the conversation to the unique needs of the system.
The same principles that are involved in building working alliances
with adolescents and family members apply to developing working relationships with community stakeholders. Therapists should approach all of these
relationships with openness and respect, listen to the needs or issues that are
being generated, and contingently respond in ways that acknowledge the
multiple perspectives that are involved. However, unlike families, the professional context in which these relationships occur requires that therapists
13190-12_Ch11_2ndPgs.indd 195
195
2/8/13 11:15 AM
move quickly to develop collaborative goals and expectations (or at least an

appreciation of the unique goals of each system) and communication plans
to efficiently monitor these goals. Again, irrespective of whether these conversations or communication plans are instituted by therapists or an agency
liaison, developing these collaborative working relationships is directly related
to FFT treatment during every phase of the processmost prominently
during the pretreatment systems engagement process but also during the
Generalization Phase, when contact with external systems becomes intensified for each case.
Ancillary FFT Support Services
For youth with juvenile justice involvement, FFT implementation can
be enhanced when offered in combination with Functional Family Probation
(FFP; Kopp & Medina, 2009). FFP was created as a case management practice
for juvenile justice workers charged with supervision of youth in a community
setting. Traditional probation supervision models are commonly organized to
monitor and intervene with only the adjudicated youth. By contrast, FFP uses
the support of family and/or community members. By strengthening family
functioning and creating broader working relationships, the likelihood for
long-term success is greatly increased with the youth being supervised. FFP
is designed to promote a relational or family focus rather than individually
focused youth-based services. Because probation and parole are temporary
services, FFP emphasizes the family as a support system to encourage and
sustain positive changes. By working with families to decrease targeted risk
factors (e.g., hopelessness, individual focus, negativity, blame) and enhance
protective factors (e.g., individual and family strengths, prosocial activities,
work, school), therapists can help provide motivation for sustainable change.
Having FFP and FFT services implemented together allows families to receive
services that are more integrated and follow a single, unitary conceptual
approach, establishing complementarity of services across the treatment and
probation domains.
FFP is based on the same core principles of FFT but uses a case management structure to facilitate change. Motivating families to attend supervision
meetings with probation staff regularly and follow through with recommendations is central to FFP. Once families are engaged and motivated, links
to natural support systems and potentially helpful community services are
established. Then, support and monitoring of the youth, family, and providers offering services and interventions are initiated. Finally, as the family
prepares to transition out of probation or parole, generalization of the new
behaviors and skills to new situations is fostered.
13190-12_Ch11_2ndPgs.indd 196
2/8/13 11:15 AM
Conclusion
Organizational climate and support from community stakeholders are
critical factors in the successful adoption and sustainability of FFT. Moreover,
the policies and practices of agencies have direct and indirect influences on
model fidelity and clinical outcomes. Therefore, attending to these features
and nurturing positive processes are critical elements of successful implementation. Agencies can use existing administrative structures to support
implementation or develop new operating procedures to support familybased work. Throughout this process, successful organizations are able to
adapt their agency culture and treatment philosophy to accommodate to
the family-focused, respect-based work that is at the heart and soul of the
FFT model. In doing so, agencies provide a supportive work environment for
therapists to learn and adopt FFT as their clinical intervention. This support
is represented in tangible features, such as therapist caseloads, time for completing case notes, participation in supervision, and planning for sessions, but
also in intangible ways, such as therapists feeling that their unique skills as
FFT therapists are viewed as a valuable resource by leadership in the agency.
These direct and indirect features have a dramatic effect on clinical practice
and, more important, on the process of improving the lives of the youth and
families therapists serve. For youth and families with juvenile justice involvement, offering FFT in the context of ancillary FFT-based services such as
FFP provides promotes coordination of services around a unitary approach
and ensures complementarity of services across the treatment and probation
domains.
13190-12_Ch11_2ndPgs.indd 197
197
2/8/13 11:15 AM
13190-12_Ch11_2ndPgs.indd 198
2/8/13 11:15 AM
12
Training and Supervision
Family therapy has a rich history of developing and implanting innovative strategies for training and supervision (e.g., H. A. Liddle, 1991; Storm,
McDowell, & Long, 2003). The emergence of distinct schools of family therapy gave rise to unique training philosophies and models (e.g., Aponte & Van
Deusen, 1981; Haley, 1976; Minuchin & Fishman, 1981; Pirotta & Cecchin,
1988), which profoundly shaped the practice of generations of family therapists (H. A. Liddle, 1991). Over the past two decades, the movement toward
providing empirically based services in the mental health field has further
influenced the emergence of highly specialized training and dissemination
models that are necessary to replicate the rigorous clinical standards that are
the hallmark of implementation in controlled studies in community settings.
Because of this, evidence-based approaches have needed to be sensitive and
responsive to the realities, challenges, and complexities of real-world, and
worldwide, implementation.
DOI: 10.1037/14139-013
199
13190-13_Ch12_2ndPgs.indd 199
2/8/13 11:15 AM
In this chapter, we provide an overview of key concepts related to

therapist training and supervision in Functional Family Therapy (FFT). We
start with a review of key concepts that are the focus of training and supervision efforts, including adherence, competence, and fidelity. Then we present recommendations for structuring training and supervision to facilitate
the quality of implementation. Finally, we review strategies for developing
effective working teams and addressing common challenges that arise in
supervision.
Importance of Training and Supervision
to Maintain Model Fidelity
As in the larger field of family therapy, our approach for training and
supervising therapists in FFT emerged from decades of experiences in training and supervision with diverse therapists across multiple settings. In our
early studies, we focused on diversity of training experiences and the impact
of our model across multiple settings and providers (e.g., Barton, Alexander,
Waldron, Turner, & Warburton, 1985). However, many of our early and
even some of our more recent training experiences occurred in the context
of highly controlled research studies or with students interested in gaining
advanced experience in implementing family therapy. Therefore, it was necessary to adapt our training and supervision protocols to facilitate competent
adherence in real-world settings. The adaptations we developed and tested
involved (a) conducting weekly group or individual supervision (or both)
remotely by phone instead of in person, (b) having therapists upload audio or
video recordings to a secure Web-based portal for review in weekly supervision, and (c) having therapists complete contact and progress notes using a
Web-based system that is specifically designed to assist therapists and supervisors in monitoring the quality of implementation and clinical outcomes.
Although such adaptations were necessary to enhance the feasibility
of adoption of FFT in community settings and to ensure sustainability of
FFT teams over time, the core intervention components of FFT remained
unchanged. They continue to consist of a clinical core represented by an
integrated set of guiding theoretical principles and a systematic therapeutic
program that relies on phase-specific change mechanisms. Please also note
that other adaptations, although not described here, have been successful
in other countries (e.g., the work of Kjell Hansson in Sweden, as noted in
Chapter 3, this volume). These supervision models have been tailored to
the different geographic, cultural, and system contexts in which the FFT
therapists work, but they retain regular oversight, review of specific cases, and
13190-13_Ch12_2ndPgs.indd 200
2/8/13 11:15 AM
monitoring of each case seen by FFT therapists. In addition, these supervision

practices also involve working as teams to provide multiple opportunities for
feedback and training.
A data-informed perspective is particularly relevant in real-world dissemination. For example, the lack of overall treatment effect reflected in
Sexton and Turner (2010; see Chapter 3, this volume) illustrates how realworld replications can provide important data regarding the relationship
between adherence and outcome even while demonstrating problems in
the dissemination training model. That study provided the basis for subsequent changes in the training model materials (e.g., Robbins et al., 2011)
that have, in turn, reflected significantly and increasingly positive overall
treatment effects (Brooks, Janer, Early, & Mason, 2012). The failure to demonstrate overall positive treatment effectiveness (Sexton & Turner, 2010)
made it clear that, given diversity in supervision practice, successful implementation of FFT requires the systematic application of FFT principles and
techniques with model fidelity. Although in dissemination therapists must
be willing and able to accommodate the model to diverse cultures, ethnicities and races, languages, delivery systems, and formal systems, therapists
cannot change the core components of the clinical model. That is, the
intent of training and supervision in dissemination is to deliver the model
with high fidelity to core principles and techniques because people do not
benefit from treatments they do not receive (Metz, Blas, Fixsen, & Van
Dyke, 2009).
Even the word systematic may underestimate the pervasive focus on
guiding principles that are expected of FFT therapists. Every therapist behavior at every moment is expected to be model based and goal directed, even
if the behavior itself is merely treading water until the therapist figures out
what the appropriate next step is for a family! Maintaining a high level of
fidelity over time is a daunting task. As therapists, it is natural for us to get
drawn into family dynamics and processes as we work with troubled youth
and their families. It is not easy to maintain a connected and empathic but
at the same time objective role, particularly during the intense moments of
conflict that are typical of early sessions of FFT.
In the face of such challenges, extensive training to enhance knowledge
and skill building helps prepare therapists to negotiate sessions with families.
However, initial training alone is not enough to sustain the long-term implementation of FFT. Ongoing feedback through a process of clinical consultation or supervision is a critical component of effective practice. Whether in
the context of a clinical trial study or community-based dissemination, clinical supervision is the primary mechanism therapists use to ensure that youth
and family members receive the highest quality of clinical care.
training and supervision
13190-13_Ch12_2ndPgs.indd 201
201
2/8/13 11:15 AM
FFT Training: Also a Phase-Based Process

During the initial training period in FFT, the focus is to build therapist
knowledge and skills. Training typically includes three key components:
(a) interactive didactic lectures (e.g., slideshows with review of recordings of
exemplar sessions); (b) weekly group supervision, individual supervision, or
both; and (c) clinical practice with youth and families. In optimal circumstances, training also includes the review of recordings of the therapists own
clinical work as well as live consultation. A common structure for training
involves the following sequence: (a) an initial training workshop, (b) implementation of FFT with youth and families, (c) participation in a weekly group
(or individual) supervision session with an expert FFT consultant or supervisor, and (d) additional follow-up training workshops or webinars over the
course of a year. Supervision and follow-up workshops are primarily focused
on therapists implementation of FFT with their own cases.
Over time, knowledge and skills evolve through clinical experience
and structured supervision. Therapists become more proficient in applying
the core principles of FFT to address any situation or challenge, whether it
be with families, other therapists, or systems. The FFT foundation becomes
even more useful over time as therapists are able to use core principles to
understand and influence interpersonal relationships in diverse individuals,
clinical populations, and settings, including relationships in the context of
clinical supervision.
Adherence, Competence, and Fidelity
As Figure 12.1 shows, supervision is the process of instilling prerequisites
and assessing performance and outcome. Supervision in FFT is structured and
focused on the ultimate goal of providing the highest quality of services to
every family. The primary focus in supervision is on examining what therapists actually do in sessions and on planning their interventions for upcoming
sessions to facilitate the competent implementation of the model. Delivering
FFT with adherence and competence is a difficult task, as families present
with a number of unique challenges and issues. Given this complexity, FFT
Prerequisites:
Knowledge
Commitment
Performance
(Fidelity):
Adherence
Competence
Outcome:
Effectiveness
Figure 12.1. The supervision process.
13190-13_Ch12_2ndPgs.indd 202
2/8/13 11:15 AM
is nearly always implemented in contexts in which FFT therapists also can

learn as participant observers as the cases of other therapists are discussed and
direct feedback is received on their own cases.
Having a solid working definition of the constructs of adherence and
competence is an essential first step in becoming an effective FFT therapist. Clinical adherence refers to the degree to which the therapist applies
the model as intended (i.e., following the manual, in accord with training and supervisory feedback). Basically, adherence is represented by the
extent to which the therapist implements the techniques of the model in
the proper sequence. Clinical competence refers to the quality with which
the techniques or model is implemented. Quality may be reflected in the
sophistication, creativity, flexibility, and breadth of the alternative avenues the therapist takes to match interventions to the uniqueness of each
familys language and ways of experiencing their world. Essentially, competence refers to the depth or skill with which the therapist applies the
model. Competence can be conceptualized as a global characteristic of the
therapists ability to implement FFT with diverse families across different
phases of treatment and as specific, phase-based skills. With respect to the
latter, for example, a therapist may have very solid motivation skills but
lack the structure and directiveness required to lead families to successful
behavior change.
Overall, competence level can be considered on a continuum. Low competence indicates a therapist who is attempting to achieve the goals of each
phase and using the skills of each phase but does the work in a rigid manner
that does not match the relational functions of the family. Low-competence
interventions often lack clinical sophistication, depth, and consistency. For
example, a therapist with low competence may give up on reframing or creating themes and allow intense family negativity to persist. Therapists with
average competence include those who are thinking somewhat complexly
about the family and the clinical process and implementing skills with moderate sophistication, depth, and consistency. High-competence therapists show
the consistent ability to think complexly about families and the clinical process and apply skills in a manner that matches to families. Interventions of
highly competent therapists are applied with depth and consistency. The
targets of intervention and strategies implemented are precise and clearly
communicated and are usually highly relevant to the family.
Model fidelity is represented as the combination of these two elements.
As such, fidelity is represented in the therapists ability to consistently implement the key elements of FFT in the right sequence (adherence) and with
a high degree of skill, depth, and sophistication (competence). Adherence
and competence are interdependent constructs, and, in reality, they both are
present as a therapist works successfully with a family.
13190-13_Ch12_2ndPgs.indd 203
203
2/8/13 11:15 AM
Knowledge
Knowledge is a prerequisite for model fidelity. Without a clear understanding and working knowledge of the core principles of FFT, it is unlikely
that therapists will be able to successfully implement the essential components of FFT in an adherent and competent manner. The knowledge aspect
of model fidelity includes a basic working knowledge of the core principles of
FFT. These principles are an important part of therapist fidelity because they
form the background of all therapists clinical actions. Although adherence
and competence are primarily represented by the therapists actual performance in sessions with youth and families, therapist use of his or her knowledge of the model to discuss cases, plan for sessions, and critically review his
or her own performance (and that of other members of their clinical team) is
an important benchmark in therapist development.
Knowledge is not simply about the facts. It is about the degree to which
the therapist uses the FFT model as a foundation to understand youth and
families and then applies this understanding to address the unique needs of
each client. Thus, more generally, therapist knowledge is in part a reflection
of the therapists commitment to and belief in the fundamental principles of
FFT. Training and supervision are designed to foster therapists knowledge of
FFT theory and techniques and to enhance therapists belief in the efficacy
of FFT and their commitment to implement FFT with high fidelity. When
viewed broadly, fidelity includes an assessment of therapists overall knowledge of the FFT model.
Performance
Ultimately, knowledge and commitment are meaningless if therapists
are not able to implement the model. The ultimate benchmark of fidelity
is therapist performance. The bottom line for evaluating therapist fidelity
is whether the therapist is able to apply his or her knowledge in the room
with families. Performance is the degree to which the therapist is doing FFT
(clinical model) as prescribed with families at every stage of the process, from
pretreatment planning and contact to direct contact with families in sessions
to additional contacts with other systems. Knowledge without performance
is not fidelity. Only what therapists put into action in their clinical work
matters.
At a general level, performance involves the extent to which the
therapist implements interventions in a manner that is consistent with the
foundational principles on which FFT is built. Are interventions relationally
focused and respectful (e.g., warm, nonjudgmental, accepting, sensitive)? Are
interventions delivered in a way that matches to family relational functions?
13190-13_Ch12_2ndPgs.indd 204
2/8/13 11:15 AM
Are interventions specific to the goals of a particular case during a specific

phase of treatment? For example, rapid response in contacting and scheduling sessions with new families and engaging key family members in treatment
is appropriate in the Engagement Phase; use of change-focus and changemeaning interventions to disrupt within-family conflict and enhance motivation for change are appropriate in the Motivation Phase. Supervision focuses
on performance within each phase of treatment as therapists work with families
from engagement through termination.
Effectiveness
Supervision also entails the careful assessment and monitoring of intervention effectiveness. Effectiveness refers to outcomes (immediate, intermediate, long term) that reflect the complex intersection of many factors: family
member characteristics, therapist adherence, therapist competence, referral
system characteristics and processes, and agency system characteristics and
processes. With respect to family-level characteristics, for example, determining adolescent outcomes is a primary focus of intervention effectiveness.
Supervisors must continually assess whether therapists are effectively reducing the referral problems that were the source of the familys initial referral
for treatment. Effective FFT practice requires continual monitoring of youth
outcomes to ensure that individual, family, and community needs are being
met. However, the bottom line is to facilitate reductions in youth referral
behaviors. Anything short of that goal fails to address the foundations on
which FFT is built.
Beyond youth behavioral outcomes, the examination of effectiveness
also includes systematic monitoring of therapist adherence and competence.
Every week, supervisors must assess both adherence and competence and
provide regular feedback to therapists about their performance. This ongoing
quality assurance and quality improvement process is as essential to ensuring
successful outcomes as the therapist interventions themselves. Without this
review and feedback process, FFT is not being implemented according to
recommended guidelines for practice.
With respect to site-related performance characteristics, supervisors can
use various sources of information to guide the supervision process, such as
referral flow and therapist caseloads, aspects of service delivery (e.g., time to
first contact and first session, average number of sessions, percentage of successfully completed cases), therapist attendance in supervision, and agency
support for the FFT team. These variables may be integral to the functioning
of the FFT team and can have a direct or indirect impact on therapist fidelity. Monitoring of a sites performance characteristics, like all other aspects
of training and supervision, is a continuous process that starts prior to the
13190-13_Ch12_2ndPgs.indd 205
205
2/8/13 11:15 AM
commencement of training activities. Dealing with these larger-scale system

characteristics is often beyond the purview of individual therapists and as
such can be quite formidable for practicing therapists. For this reason, we
encourage therapists to be part of clinical teams that have a clear leader who
is responsible for maintaining support for FFT practice.
Structure of Supervision
Case discussion in a group format is the primary mechanism or modality of training and supervision in FFT. Workshops are important for imparting knowledge of basic concepts and techniques, but it is in the review of
therapists actual clinical practice with their own cases that this knowledge
is applied and solidified. As such, we consider weekly supervision to be a
fundamental aspect of effective clinical practice. A fundamental assumption
is that because supervision focuses on implementation of the core principles
and techniques of the model, the entire team benefits from individual case
staffing. The recommendations and strategies discussed in one therapists
caseload may be relevant for helping other therapists with their own cases.
Working in groups thus provides increased opportunities to expose therapists to many clinical issues without having to spend years accumulating
this experience. Also, working with groups provides a context for therapists
to think and provide feedback about other cases. This is important not just
because it provides multiple perspectives but also because it gives therapists a
chance to process the FFT model and its application without some of the bias
or natural defensiveness that is associated with reviewing their own cases.
Sometimes this objectivity gives therapists important information about their
own personal strengths and weaknesses. In fact, once a therapist is able to
identify adherence and competence issues among other members of the team,
they are able to accept (or even see) problems in their own work.
The first step in group supervision occurs prior to meeting with the
team. Just as we expect therapists to plan for sessions with families, we believe
that effective supervision requires careful planning and forethought. The
planning process is important for tailoring goals for each supervision session
to the unique needs of the families, therapists, and site. The planning process
should involve a careful review of the immediate goals for each supervision
session. The immediate goals should always include a plan for reviewing and
enhancing performance in three domains: family, therapist, and site. At the
family level, supervision is focused on the specific aspects of a case, including
how far along in the treatment process the family is, what their relational
functions are, what interventions have been tried, what has been effective,
and what the plan for the session was.
13190-13_Ch12_2ndPgs.indd 206
2/8/13 11:15 AM
At the therapist level, the supervisor reviews what areas the therapist
or team is struggling with and develops a plan to structure opportunities for
feedback to address these needs. For example, thinking about themes for a
case, reviewing a slide, or leading a structured role-play using a case as an
example are all possible strategies for building skills. In planning supervision
sessions, we encourage supervisors to attend to the makeup of the supervision group. A group with less experienced or lower-fidelity therapists requires
more direction and feedback. A group with more experience or higher fidelity
(greater competence) may require less direction but more facilitation. With
respect to the latter, for example, the supervisor functions as a guide who
initiates discussions and moves the session along to ensure that all goals are
met but does not necessarily provide feedback or recommendations. A group
with mixed levels of experience and fidelity requires sensitivity to all needs
enough directives to support therapists with more basic needs without losing
the interest of or learning opportunities for the more competent therapists.
Supervisors also are expected to review features of the site or context
that support or interfere with team performance. Issues such as whether therapists have adequate time to participate in supervision, plan for sessions, and
complete paperwork; whether the site values and rewards therapist performance; and whether funding for FFT services is secure are critical considerations for helping the team function at peak efficiency.
The weekly clinical supervision sessions are typically divided into two
key activities: fidelity review and case planning. The goal of both activities is
to enhance the quality of implementation; however, the focus varies. Fidelity
review focuses on the quality of what was done in prior sessions. Case planning focuses on what the therapist is going to do next.
The supervisors fidelity review is guided by several assumptions. First,
the impact of FFT is driven by what therapists do with family members. This
perspective respects the therapists role as an agent of positive change for families. Second, supervision is a critical way to enhance the quality of what therapists do. This perspective places a high value on the goals of the supervision
process. Third, the more cases that are reviewed in supervision, the broader
the impact of supervision on therapist fidelity and, in turn, on clinical outcomes. This perspective assumes that every case can benefit from having
extra eyes reviewing what has been done and planning for future sessions.
Fourth, therapists learn as much from their successes as from their failures;thus, supervision (and fidelity review) cannot solely focus on difficult
cases. This perspective conveys a strength-based focus that values all aspects
of the therapists work. Fifth, what defines fidelity varies by phase of treatment, so fidelity review should include a range of cases across phases. This
perspective respects the unique skills that are required of therapists at different points in the treatment process.
13190-13_Ch12_2ndPgs.indd 207
207
2/8/13 11:15 AM
Case planning is different from fidelity review in one key respect:

Fidelity is about what the therapist did with the family in the most recent
session, but case planning is about determining what to do next. Planning for
sessions is a critical component of FFT. Therapists who spend adequate time
planning for sessions (e.g., reviewing functions, matching interventions to
phase and family) are more effective than therapists who rely on spontaneity.
Structuring case staffing helps ensure that supervision is effective in helping
therapists plan for upcoming sessions with families. Case planning requires a
supervision style that is direct and focused. The specific focus should always
be on helping the therapist define the goals for an upcoming session and
develop an intervention plan to achieve these goals. In doing so, the goal of
supervision is to help the therapist line up immediate in-session goals with
the intermediate (end-of-session or phase-based outcomes) and long-term
behavioral goals. As evident from this description, case planning varies by
phase of treatment. During each phase, the goal is to develop an intervention plan that addresses specific relational or behavioral targets in a way that
matches the familys relational functions and individual styles. For example,
during the Motivation Phase, it is useful to expect and plan strategies to help
families deal with high conflict and negativity or widespread denial, avoidance, or minimization of concerns or conflicts.
Assigning tasks in supervision may be helpful in the planning process.
Given that therapists have different learning styles, with some favoring an
experiential approach, some favoring dialogue, and some favoring an educational approach, the activities and nature of tasks may vary from week
to week. For example, a therapist who favors an experiential approach may
benefit more from role-plays in which each member of the team takes a role
in the family. Or, for a therapist who favors a more conceptual approach,
supervision may involve brainstorming five reframes that may help the therapist disrupt negativity and develop a relational theme. The nature of the tasks
should vary by group makeup and individual therapists needs. Team members
with basic adherence needs require more examples, whereas team members
who are able to more competently implement the FFT model should be able
to generate more examples and ideas on their own. In all instances, however,
assigned tasks should be direct and focused on a specific goal, such as developing a behavior change plan that matches relational functions or practicing
change-focus techniques.
Effective case planning has several core components. First, and perhaps
most important, the supervision group must have a general understanding of
the family and where the therapist is with the case. This understanding may
contain some personal elements (e.g., who is in the family, divorce, history
of trauma) and ecological elements (e.g., justice involvement, school problems). However, just as in therapy sessions, it is important that the super208 functional family therapy for adolescent behavior problems
13190-13_Ch12_2ndPgs.indd 208
2/8/13 11:15 AM
visory group not get bogged down in extensive discussions about historical
features or characteristics of individual family members. These discussions of
content may be interesting but often serve to derail a focus on interpersonal
or relational issues. Second, a cursory review of what has been implemented
with the family is often a useful way to orient the team about what to do next
with the case. For example, how has the therapist progressed through the
Motivation Phase, what themes seemed effective in reducing conflict, and
how has the plan been tailored to match the relational functions? Third, the
team should help the therapist determine the relational and behavioral goals
for the next session. In part, this means helping the therapist identify the
most pressing issues that need to be addressed for the family. Fourth, the
team should help the therapist develop individualized plans to accomplish
the goals in the next session. Finally, it may be useful to practice specific
skills to be used in the next session (as described above).
Establishing and Maintaining a Working Team
Supervision is a relational process that is geared toward the goal of providing the highest quality of care to youth and families. As such, despite
the relational nature of the process, supervision is inherently task oriented.
It is the supervisors responsibility to create a context in which individual
therapists, the working group of therapists, the agency, and community partners are working toward a common goal. Like the FFT clinical model, there
are foundations and principles for the supervision process that remain relatively stable, which include respect for the individual and unique differences,
strengths, and characteristics of each therapist and a genuine acknowledgment of the professional role of each therapist who has chosen the path of
working with troubled youth and families.
Enhancing Motivation to Practice With the Highest Fidelity
Supervising team members and colleagues is not simply about building relationships. It is about influencing therapist behaviors. In the case of
supervision, it is about getting therapists to continue their development to
competently implement FFT. The early work in this process involves building effective working relationships and enhancing therapists motivation to
practice FFT with the highest quality. This is accomplished by establishing a
personal connection with each therapist, creating a coherent team that works
together and accepts the supervisors role, strengthening or building relationships between therapists, enhancing therapist confidence, and establishing a
structure for supervision.
13190-13_Ch12_2ndPgs.indd 209
209
2/8/13 11:15 AM
Successful working relationships are evident when therapists are actively

participating in the supervision process, presenting cases, and providing recommendations to other members of the team. Successful development of a
culture of motivation to build fidelity and improve clinical outcomes is reflected
in the therapists commitment to using supervision as a mechanism for building adherence and competence; it is also seen in therapists acceptance of
the challenge to better understand and apply FFT with youth and families.
The formation of this working relationship is most evident when therapists
are open to discussing their challenges in implementing the FFT model or
when they acknowledge their areas of weakness. This willingness to explore
how to improve their professional practice is fundamental to the supervision
process irrespective of whether the supervisee is a new therapist or has years
of experience working with youth and families.
Supervisor Contingency: Therapists Fidelity Levels
The goal of the clinical supervisor is to help each therapist progress
from low fidelity to high fidelity over time. As teams evolve over time and
team composition changes, supervisors will likely have a team that includes
therapists across all levels of fidelity. In the group supervision setting, the
goal is ensure that all therapists are engaged to participate and learn from
the case reviews and session planning so that they continue to develop
their FFT knowledge and performance. To meet all the unique needs, therapists with high fidelity might be asked to take a more senior therapist role
and may sometimes lead the session planning discussions. In doing so, this
gives therapists with high fidelity new ways to enhance their practice. To
help therapists with low fidelity (who are working on basic adherence) stay
engaged and participatory in a high-fidelity team members case review or
session planning (more focused on competence issues), supervisors might
summarize the key performance tasks embedded in the review or planning.
Alternatively, supervisors might ask the low-fidelity therapists to summarize
what they heard were the key performance task goals for that familys next
session and how that case review feedback can help them with one of their
own specific cases.
Therapists with low levels of fidelity require considerable guidance from
the clinical supervisor. The guidance for these therapists must be concrete
and direct. Therapists with average or moderate levels of fidelity can focus on
the critical adherence elements of FFT and can offer suggestions to and take
suggestions from the clinical supervisor and other team members. These therapists can absorb and learn from other case staff who are more group focused
and can demonstrate initiative in giving and receiving feedback in group
supervision. Average- or moderate-fidelity therapists require suggestions and
13190-13_Ch12_2ndPgs.indd 210
2/8/13 11:15 AM
directions rather than the more concrete teaching approach required for less
mature therapists. Therapists with high levels of fidelity demonstrate performance of FFT with both high adherence and competence. These therapists
review their cases in a model-focused manner and demonstrate high levels
of participation and learning in group supervision. For these therapists case
reviews, the clinical supervisor monitors and suggests, with little need for
directing them with concrete task feedback.
Keeping all therapists with different levels of fidelity engaged, participating, and learning in a group setting can be tough. If the supervisor remains
focused only on basic adherence development, he or she may lose the attention of therapists with high fidelity. Conversely, if the supervisor remains
focused only on competence development, he or she may lose the attention
of and learning opportunities for the therapists with low fidelity. The supervisor needs to be creative and thoughtful about how to match and support
the learning needs and participation styles of all therapists during a group
supervision session. The working group must ultimately be a source of peer
support, identity, and model fidelity development.
Intervening to Enhance Adherence and Competence:
Quality Improvement
Building adherence and competence requires an ongoing commitment to quality assurance and quality improvement. Quality assurance is a
monitoring- and tracking-based task. Supervisors constantly monitor and
assess the levels of adherence and model competence during each formal
supervision encounter (e.g., staffing) and in each informal case discussion.
Systematically assessing the knowledge and performance issues overall and
phase-based adherence and competence forms the basis of supervision interventions. Quality improvement is the action of the supervisor to improve the
delivery of FFT by the therapist. Quality improvement interventions take
place each time the supervisor makes suggestions or gives input to a case discussion, each time the supervisor talks with a therapist, and each time the
supervisor focuses a working group on specific issues of adherence and competence. Quality improvement may be teaching oriented (e.g., discussing a
principle or issue of the clinical protocol) or discovery oriented, taking the
form of guided discussions (led by the supervisor) or a group brainstorming
discussion. All quality improvement processes are intended to address specific
issues that match to the therapists level of skill and learning style. Initially,
the primary focus of most supervision sessions is to enhance adherence and
deal with specific adherence challenges. As therapists become more consistently adherent to FFT, the focus of supervision shifts to include issues of
clinical competence and sophistication.
13190-13_Ch12_2ndPgs.indd 211
211
2/8/13 11:15 AM
On the basis of the therapists profile of adherence and competence, the

clinical supervisor has a number of ways to improve the quality of services
provided to youth and families. The choice of how to specifically intervene
depends on (a) whether the primary issue is one of adherence or competence,
(b) whether the domain is one of knowledge or performance, (c) the team
makeup (more and less experienced therapists; therapists with low or high
fidelity), and (d) the supervisors relational understanding of the individual
therapist.
Teaching is the primary pathway for generating knowledge of specific
techniques in FFT. Misunderstanding the core principles or the clinical procedures, at either a basic level (adherence) or a complex level (competence),
is among the most common problems that lead to difficulties implementing
FFT. When knowledge is the issue, supervision must be focused on developing the understanding necessary to improve adherence or competence. This
can occur by discussing the conceptual principle behind an issue related to
the core of the therapists struggle or by reviewing slides or training materials.
For a therapist with low fidelity, the clinical supervisor may decide to tell or
instruct the therapist and group at this moment. For a therapist with average
or moderate fidelity, the supervisor may focus the discussion on the principle
at issue and facilitate a group discussion. For a therapist with high fidelity, the
supervisor would facilitate a group discussion about the conceptual principle.
Thus, teaching interventions are targeted primarily at improving understanding of the model and principles for each group member.
In some circumstances, therapists may react defensively to the teaching
process (irrespective of how it is delivered) and may challenge the utility of
a specific technique or issue. At this point, the focus of supervision becomes
one of motivation. It is important to not adopt a challenging or one-up style.
The supervisor should go back to listening and acknowledging the therapists
perspective and determine whether the therapist is struggling with a core
principle or concept or is having difficulty implementing a new technique or
systemic focus. In these circumstances, the therapists self-efficacy beliefs may
be challenged, and he or she may be falling back on prior experiences (before
FFT) because that is where he or she is most comfortable. The supervisor
should attempt to ascertain whether the therapists struggle is due to pessimistic, blaming views about individual family members. Some situations or family members may push the therapists buttons in a subtle or overt way, making
it difficult for the therapist to create a motivational context or demonstrate
respect to family members. It is common in these circumstances for therapists
to react with defensiveness or negativity toward individual family members,
the clinical model, or the supervisory process. It is critically important for
the clinical supervisor to slow the supervision process down to identify these
processes, acknowledge the therapists reactions, and facilitate a supportive
13190-13_Ch12_2ndPgs.indd 212
2/8/13 11:15 AM
and directed discussion to help the therapist shift the focus back onto what
needs to happen in the session (from the FFT model perspective).
Case-specific suggestions are another way to improve either adherence
or competence through direct suggestions for the specific case under discussion. In fact, the majority of feedback in FFT during supervision is delivered via case-specific, focused suggestions. These suggestions are important
at every level of model implementation, from engagement to generalization
and from assessment to implementation. All case-focused suggestions are
aimed primarily at improving the performance aspect of either adherence or
competence. When targeting competence, the goal is to help the therapist
match to the unique family and apply the FFT model contingently so that it
meets the unique requirements of that specific case.
One supervision technique to provide case-specific suggestions and
tasks is to facilitate a role-play with therapists. Some therapists thrive and
seek this type of practice, whereas some shy away from role-playing. Thus,
it is important to use role-playing in supervision in a contingent manner.
Role-playing provides a unique opportunity to see how therapists perform in
the momentdo they stumble, do they get overwhelmed, do they attempt
to use the various phase-based techniques, are they responsive to the cues
and reactions of the family members? For therapists who are strong in the
knowledge domain but weak in the performance domain, role-playing can
help build performance skills.
Maintenance Process
As the adherence and competence of individual therapists grow, the
clinical supervisors leadership style changes. Most teams experience therapist
attrition and the addition of new team members over time, and so team relationship building and motivation development (and maintenance) always
remain important. As teams change, the supervision goal remains constant;
that is, the focus continues to be on therapist fidelity across a range of clients
and situations. The supervisors role remains an active one as he or she helps
therapists continue to advance their competency levels and watches for drift
in the application of the model. Using the tools described in this chapter,
supervisors carefully monitor each therapist to identify model drift when it
occurs and to strategically use team members with higher fidelity to create
peer-to-peer case-level supervision. In addition, supervisors must continue to
monitor the service delivery context within the agency, advocating for the
team and a delivery context that supports FFT.
The supervision goals of competence development and maintenance
continue for the life of the team. It is usually when a team member leaves or
when a new member is added that the overall group dynamics change to the
13190-13_Ch12_2ndPgs.indd 213
213
2/8/13 11:15 AM
degree that the supervisor may need to begin with a renewed focus on early
team alliance and motivation development and help the new therapists (and
sometimes even therapists who have been on the team for some time) move
quickly into the development of adherence and competence.
The clinical supervisor must assess individual needs and group needs on
a continual basis to ensure that the group remains focused on adherence and
competence. It may be that in a stable group with growing competence, the
supervisor can become less and less directive overall. However, to continue
the development of the group, the supervisor may still find it useful to review
selected clinical chapters or assign homework tasks that will help therapists
develop knowledge and skills in new areas. For example, it may be beneficial
to have the team identify resources for behavior change that are relevant for
the clinical populations being served at their agency.
Strategies for Addressing Common
Supervision Experiences
Experiences commonly encountered in supervision include therapists
defensiveness regarding feedback, their focus on the details of content, and
their experience of feedback as overwhelming. The following sections discuss
each of these issues in turn.
Therapist Defensiveness Regarding Feedback
For therapists, supervision is a relational process that involves the courage to review their work and make a commitment to change. During this
process, therapists may take constructive feedback and recommendations
personally. It is common for therapists to see these comments as a criticism
of their professional capabilities. As such, therapists may experience some
negative emotions over the course of their evolution in FFT. These emotional reactions can be exacerbated by the inherent challenge of working
with very difficult clients. These reactions are a natural part of the journey
for therapists. At any time, one, several, or all of the therapists on a team
may be struggling with implementing the model. And, just as with families,
when faced with such challenges, it is a common reaction to externalize the
problem on some other source. This is a natural process for all of us. This
externalization may take the shape of criticisms directed toward the model,
the supervisor, the agency, or other issuesall of which can serve to derail
the focus on enhancing the adherent and competent delivery of FFT. Thus,
it is the supervisors role to systematically monitor this process and redirect
therapists back to the goals of the working group. In doing so, the supervisor
13190-13_Ch12_2ndPgs.indd 214
2/8/13 11:15 AM
is responsible for helping the therapists remain motivated and committed to

providing the highest quality of services to youth and families.
In both individual and group supervision contexts, strength-based statements can be helpful. Strength-based statements, as well as recognition and
appreciation of their ongoing efforts and successes, are key interventions
supervisors can use to boost therapist self-efficacy and motivation to continue
in their development. Supervisors should make sure to catch therapists
doing good work (e.g., being extremely flexible when scheduling sessions
with families, being up-to-date with their progress notes, having sessions with
all their families in 1 week) and individually and publicly congratulate and
appreciate them.
The use of reframing in response to therapist blame or negativity (e.g.,
about a family, a referral source, an agency policy) is also a useful supervision
intervention that can help focus attention on therapists struggles and help
them take responsibility for the struggles while acknowledging the frustration, stress, or other difficulties in a way that offers hope and support for successful resolution. Reframing helps therapists find a way out of the defensive,
blaming, and negative emotion that they often confront when struggling
with a new model of therapy. When done successfully, reframing helps refocus
therapists on the challenges they face in ways that are not blaming.
Acknowledging, understanding, and respecting therapists statements,
views, and emotions and their struggle in working with a concept, issue, or
family is a critical component of supervision. It is important to note that this
acknowledgment is more than simply a supportive or empathic reflection.
This acknowledgment is intended to convey an appreciation of therapists in
their struggle, a focus on the difficulties they are experiencing, recognition
of their strengths, and a sense of shared commitment. In the professional
context of group supervision, communication should be direct and genuine.
Supervisors should tackle difficult issues head on in a nonchallenging and
nonblaming manner by putting difficult struggles on the table in a respectful manner. Working alliances between therapists and supervisors are built
through this respect and directness.
Therapists Focus on the Details of Content
A common problem in supervision is that the team becomes overly
focused on the details or content of all of the problems or issues that are
involved with a family. This is difficult because consultation is a time-limited
activity that includes providing as much support to as many team members
(and families) as possible. Additionally, therapists who have a tendency to get
lost in the contentthe details of every family story, every family example,
every particular of a family event, and so forthoften have a more difficult
13190-13_Ch12_2ndPgs.indd 215
215
2/8/13 11:15 AM
time keeping their eye on the immediate session goals and overall treatment
goals for the cases they are presenting in supervision. This can result in larger
numbers of sessions per phase, longer duration of time in meeting phase goals,
or loss of family motivation. Pointing process is a tool that can be used to
appreciate therapists tendency to become overly focused on details of their
cases. Pointing process allows the supervisor to refocus therapists on the relational aspects of the family. The supervisor needs to be clear and specific with
feedback; for example,
As you discuss what you did in your last session, it sounds to me that
you are getting caught up in the behavioral details of that specific crisis
and losing sight of the chronic family patterns. In doing so, you can miss
opportunities to use the relational interventionsspecifically, changemeaning interventions like reframing or themesto respond to that
story in a way that helps you progress toward your session goals of reducing blame and negativity between the parent and adolescent.
Therapists Experience of Feedback as Overwhelming

There are many reasons why therapists may get flustered or overwhelmed
by feedback: (a) The feedback is not delivered in a way that matches to their
learning needs, (b) they feel criticized or embarrassed, (c) the feedback is
confusing because it is vague or off-target, or (d) too much feedback is provided at one time. Feedback should be clear and specific. What may appear
to be therapist resistance to implementing feedback may instead be confusion about exactly what that feedback meant they should do differently in
the session. Consider how the behavior change strategies for helping families
be clear and specific in their communications can be applied to the process
of conveying feedback. For example, instead of clean up your room, the
therapist would recommend saying, Please pick up your books and put them
on the shelf, hang up your clean clothes, and put your dirty clothes in the
basket. If therapists do not understand the recommended session strategies
during consultation feedback, then they will be unsuccessful attempting to
implement those strategies in sessions.
One recommendation is to end each case planning or case review session with a summary of the key pieces of feedback or performance recommendations. In doing so, the supervisor should avoid providing too many
recommendations. A strategy to help therapists walk away from consultation
with a clear understanding of the feedback is to focus on only a few strategies.
For example, try to end case planning with the top three activities to try in
the next session. A therapist with more experience or mastery of the model
generally will be able to incorporate more feedback into future sessions without becoming overwhelmed than will a therapist who is new or struggling
13190-13_Ch12_2ndPgs.indd 216
2/8/13 11:15 AM
with particular aspects of the model. Contingently giving feedback in a way

that maximizes therapist performance in session is the goal.
Conclusion
Supervision is a core component of effective FFT practices. The supervision process provides a forum for case discussion and interpersonal connections that help create a context that ensures that every youth and family
receive the highest quality of care. Successful supervision involves careful
planning and strategic action and the implementation of interventions that
are matched to individuals and relationships. Consistent with our approach
to working with families, the supervision process is rich with respect and
acceptance and involves considerable efforts to build or maintain effective
working alliances with members of the team.
There is no one specific or right way for leading supervision. Each supervisor, therapist, team, and site has its own unique characteristics that will
undoubtedly influence how this process unfolds. Supervisors need to match
their skills and leadership style to those of individual therapists and the group
to facilitate this process. Matching occurs at several levels and includes the
supervisors own personal style, the unique characteristics of each therapist,
the groups developmental level, and the site context. As when implementing FFT with families, the clinical supervisor must be flexible, contingent,
and responsive to the group process. In doing so, the supervisor is able to
enhance model fidelity to ensure the best outcomes possible for the youth
and families in the community.
13190-13_Ch12_2ndPgs.indd 217
217
2/8/13 11:15 AM
13190-13_Ch12_2ndPgs.indd 218
2/8/13 11:15 AM
13
Application of FFT to
DistinctPopulations
The notion of matching, which is core to the Functional Family Therapy

(FFT) model, calls for the development of specializations for specific and frequently encountered problems among youth and families referred for FFT
services. Specialized strategies provide therapists with groups of concepts,
techniques, and syndrome-specific goals that can match all families within
a class (e.g., gang-involved youth, the presence of disorders such as posttraumatic stress disorder [PTSD]) but still require the FFT matching to the
unique characteristics of each. The traditional entry portal for adolescents
and their families into FFT has been through various forms of adolescent disruptive behavior disorders, particularly ones that involve delinquency, conduct disorder, oppositional defiant disorder, violence, and the like. Various
FFT research programs and clinics certified in FFT have, over the years, also
addressed additional behavioral patterns, individual diagnoses, and diverse
comorbid expressions. In general, youth referred for FFT have been identified
DOI: 10.1037/14139-014
219
13190-14_Ch13_2ndPgs.indd 219
2/8/13 11:15 AM
as expressing predominantly externalizing disorders. However, a significant

number also have experienced internalizing disorders such as depression,
bipolar or cyclothymic expressions, and increased risk for suicide. Substance
use and abuse have been present in the great majority of referred youth,
including youth with co-occurring externalizing or internalizing problems.
After its first decade of clinical and research development (Alexander &
Parsons, 1982) and subsequent replications (Alexander et al., 1998; see also
Elliott, 1997), specialized application of FFT to particular subpopulations,
with concomitant increased conceptual and clinical development, began to
emerge, along with empirical support for such specializations. Most notably,
Waldron and her colleagues developed a clinical and research base for FFT
for families of youth involved with alcohol and drugs (FFTAD; Waldron &
Brody, 2010; Waldron & Turner, 2008). With more than a dozen randomized
controlled trials and other treatment outcome studies completed or currently
underway, FFTAD has received the most rigorous evaluation of the specialized approaches and is now being disseminated in English and Spanish.
Another specialization to emerge, FFTIR (integrated reentry), had its
roots in the series of FFT treatment outcome replication studies conducted
by Barton, Alexander, Waldron, Turner, and Warburton (1985). FFTIR has
since been implemented with youth reentering their natural environments
from juvenile justice incarceration settings, residential treatment programs,
and other child welfare residential and out-of-home placements.
More recently, population-focused FFT specializations and research
evaluations are being applied to gang-involved youth (FFTG), youth referred
from child welfare settings (FFTCW), juvenile justiceinvolved youth with
histories of trauma and behavioral symptoms of PTSD who require a traumafocused intervention (FFTTF), and depressed youth (FFTDEP). In applications such as these, the FFT outcome goals and criteria have expanded from
the earlier gold standard of reducing juvenile recidivism to include diverse
outcomes that are specific to the populations served, such as eliminating or significantly reducing drug use, depression, anxiety, suicide risk, referrals to ancillary child welfare and health resources, and other mental health outcomes.
The table of research outcomes in Chapter 3 (Table 3.1, this volume)
provides more specific information about the evidence base for these specializations. In some instances, there is extensive evidence documenting the
efficacy of FFT with specific populations, such as substance abusers, whereas
in other areas, research is ongoing to examine the efficacy of the approaches.
For example, Waldron and her colleagues recently completed a randomized
controlled trial evaluating FFT and cognitive behavioral therapy (CBT)
interventions for working with youth with co-occurring depression and substance abuse (Rohde, Waldron, Turner, Brody, & Jorgensen, 2012). In addition, although we provide some data below to support the promise of FFTG
13190-14_Ch13_2ndPgs.indd 220
2/8/13 11:15 AM
and FFTCW, formal research is also underway to evaluate these approaches.

Treatment development and pilot studies are also being conducted with FFT
TF (Kerig & Alexander, 2012).
In each of these specializations, FFT therapists work with funding and
referring sources to identify specific outcome goals and culturally relevant
criteria for success. This integration with larger systems occurs prior to overall
program initiation at a given agency but is repeated and individualized for
each family and their unique strengths and challenges. Specific specialized
foci and techniques are brought to each youth and family when needed. Such
specialization may require a few more sessions over a longer time frame to
match the severity of problems that are often presented by youth and families
experiencing delinquency plus significant levels of trauma, substance abuse,
gang involvement, or reentry to the natural environment from highly structured residential environments. Beyond this individualization, however, FFT
always works toward the bottom-line criteria that all families face within a
given system such as substance abuse, criminal behavior, child neglect and
abuse, or truancy.
The rest of this chapter describes the best developed FFT specializations, all of which involve working with major treatment systems (e.g., child
welfare, juvenile justice) and each of which includes formal independent
evaluation (although usually not well-controlled randomized trials). As such,
they are considered to be promising programs but not as yet evidence based.
And note that to date, each of these specializations has involved treatment
teams already trained in the core FFT model (as described in this volume).
In other words, the specializations build on the strong basis of the same FFT
model represented in this volume and all of our research and training. This,
too, represents a guiding principle of FFT for many decades: First, build a solid
core (family, therapy team, treatment system), and then add specializations
that represent accommodations to specific populations and syndromes.
FFT for Gang-Involved Youth
FFT therapists frequently encounter youth who are gang involved or
deemed to be at risk for gang involvement. In our recent review of data from
more than 230 sites currently implementing FFT in community settings, we
produced estimates ranging from 0% to 15% of the referred youth being gang
involved. FFT for gang-involved youth follows the same phasic model as
FFT. Given the general severity of risk factors, however, FFTG is designed
to involve more direct treatment as well as preparation prior to treatment.
On the basis of current FFT involvement with more than 70 gang-involved
youth, FFTG may average 20 to 30 sessions generally over a period of 4
application of fft to distinct populations
13190-14_Ch13_2ndPgs.indd 221
221
2/8/13 11:15 AM
to 5 months. The Behavior Change Phase of FFTG involves modeling,

directing, training parents and youth, and applying specific techniques such
as effective parenting, communication training, behavioral contracting, and
contingency management. Additional skill-training interventions such as
problem solving and other behavioral intervention strategies are included
using a menu-driven process from the behavior therapy literature (e.g., listening skills, anger management, parent-directed behavioral consequences,
improved parental supervision).
FFT for Youth With Alcohol and Drug Involvement
Substance use and abuse during adolescence take a multitude of forms,
with wide variations in substances used, quantity and frequency of use, and
negative consequences experienced. Substance abuse is often viewed as just
another manifestation of adolescent disruptive behavior. However, the specific
pharmacological effects and addictive properties of alcohol and illicit drugs
have important and unique implications for treatment compared with FFT for
other referral problems. The development and maintenance of substance use
behaviors are also uniquely influenced by the immediate social environment,
including alcohol or drug involvement of peers, parents, or both; the availability of alcohol and illicit substances; and prevailing societal influences (e.g.,
tobacco and alcohol taxes, stringent law enforcement, bans on nonprescription medications). Unlike many disruptive behaviors, substance use tends to
be covert, and parents, teachers, or other health professionals may not be aware
of the extent of an adolescents drug or alcohol problems. Similar to youth with
other disruptive behaviors, however, the majority of drinking or drug-abusing
teens are unmotivated to change and resistant to treatment, often entering
treatment only under a court mandate or in lieu of school suspension.
The influence of the family on the development and maintenance of
substance use problems is widely recognized. Parent and sibling use, family
members attitudes toward use, poor family management practices, disturbed
marital and family relationship functioning, and myriad other family factors
have been linked to adolescent substance use. These factors represent interdependent and bidirectional influences. Treatment outcome studies have
shown that family-based interventions are associated with higher rates of
treatment engagement and retention, significant reductions in substance use,
and improved functioning in other behavioral domains (Stanton & Shadish,
1997; Waldron & Turner, 2008).
FFT for families of adolescents with problem drinking or drug use has
emerged as a well-established treatment for youth with alcohol, marijuana, and
other illicit substance use disorders (Friedman, 1989; Waldron, Slesnick, Brody,
13190-14_Ch13_2ndPgs.indd 222
2/8/13 11:15 AM
Turner, & Peterson, 2001; Waldron & Turner, 2008). There are a variety of
behavior change techniques for the unique problems associated with substance
abuse. However, the behavior change program selected for families is based on
the specific problems associated with each family and on the family functions
identified during the Engagement, Motivation, and Relational Assessment
Phases. When both the adolescent and the parent are involved in substance
use, conducting a functional analysis of their use behavior (i.e., identifying
antecedents and consequences of use, as well as the quantity, frequency, and
circumstances surrounding use) can help reinforce the relational nature of the
substance use problems and identify specific ways in which the adolescent and
parent can support each other in reducing use. This technique can be effective in motivating parents to address their own use and can be introduced as
an informational exercise for parents who resist changing their own behavior.
Positive family activities, communication training, and problem-solving
skills training are considered core behavior change topics in FFTAD to
improve family relationship functioning. Despite improvements in family
relationships, however, helping a youth achieve abstinence or meaningful
reductions in drinking or drug use can be challenging when the youth experiences urges and cravings to use illicit substances. Skills training for coping
with urges and cravings include identifying triggers (i.e., antecedents) of use
and implementing a variety of strategies to avoid high-risk situations. Another
strategy, referred to as urge surfing, involves an imagery technique that helps
youth overcome urges by observing them and becoming immersed in them
during the brief moments urges typically last. All family members with addictive behaviors can participate in activities focusing on coping with urges and
cravings, and family members without addictive behaviors can be included
in discussions during sessions and at home in ways that fit their relational
functions in the family. If the adolescent has a contact or midpointing function with one or both parents, it may be possible to have the adolescent seek
support from the parents, who may or may not have addiction or recovery
experiences themselves, to help monitor and cope with urges to use. Similarly,
relapse prevention techniques can be discussed with the entire family, and
specific responsibilities can be assigned to family members to help support
the adolescents sobriety. For example, when an adolescent girl is invited to
a party, if the mother has a distancing function, she could help her daughter
identify triggers for drug use the daughter might encounter at the party and be
available by phone to pick the daughter up as part of a safety plan.
Communication between the adolescent and the parent is often compromised because of escalated reactions to the adolescents drug use. A common
FFT behavior change strategy to help individuals regulate negative moods
and emotions (e.g., anger management, coping with negative thoughts) can
be effective in this situation. The process involves examining and challenging
13190-14_Ch13_2ndPgs.indd 223
223
2/8/13 11:15 AM
automatic and irrational thoughts associated with a particular situation and

then demonstrating the link between these thoughts, negative moods, and
poor family communication. For example, a mother might say,
When I see Justin getting high, it makes me think about my uncle, who
got hooked on heroin and ended up homeless and sick. We were very
close, and when he died, I had a hard time getting on with my life. With
Justin, Im worried all the time. I beg and scream, but he just gets angry
and leaves, which makes me worry even more because I dont know
whats happening to him.
By challenging the belief that Justin will follow the same path as the moms
uncle, the therapist can help her develop alternative thoughts to support positive copingfor example, Justin isnt the same person my uncle was, and
he probably doesnt appreciate the comparison. Im just going to thank him
for coming home on time. This process deescalates emotional responses and
helps the family implement more effective communication strategies. The particular menu of behavior-change topics and strategies addressed will depend
on the substance-related issues of the adolescent and other family members.
The implementation of specific topics will depend on the openness of family
members to being supportive of the recovery process and on the appropriate
matching of change strategies to relational functions in the family.
FFT With Contingency Management
for AdolescentDrug Involvement
Contingency management (CM) is an individualized, empirically supported, and behavioral approach that is based on a conceptualization of
substance use and related problems as learned behaviors that are, in part,
initiated and maintained in the context of environmental factors. FFTCM
integrates elements of CM into FFT services by providing low-cost tangible
items (e.g., gift cards for books, restaurant coupons) to youth who regularly
demonstrate a targeted behavior change while enrolled in FFT. Sometimes
incentives take the form of vouchers that can be exchanged for cash or
other goods or services. The incentives are always contingent on evidence
of the desired behaviors, typically abstinence from substance use but also
other identified goals of treatment, such as treatment attendance, homework
compliance, or job-seeking behavior. This specific treatment intervention is
based on clinical research that has demonstrated its effectiveness in reducing
substance use disorders and increasing treatment attendance.
As in all FFT behavior change sessions, the process of completing a functional analysis, discussing urine analysis results, and discussing incentives in
13190-14_Ch13_2ndPgs.indd 224
2/8/13 11:15 AM
FFTCM sessions is done in a manner that matches relational functions in

the family. Because the primary target behavior in an intervention for substance abuse or dependence is the substance use itself, motivational incentives
are provided contingent on abstinence from drug use. However, a variety of
behaviors can be targeted for change using contingency management procedures. Within the FFT component of the program and in the later phases of
the CM intervention, other behaviors such as therapy attendance, homework
compliance, or school attendance may be the focus of intervention. Typically
a behavior that is problematic and in need of change is identified as the target
behavior. It is vital that the behavior be observable and measurable. The target
behavior is the centerpiece of the behavioral contract, which, in turn, provides
the framework within which incentives can be successfully used (Petry, 2000).
The choice of reinforcers is a crucial element in the design of a motivational incentives program. Incentives that are perceived as desirable are
likely to have a much greater impact on behavior than are those perceived to
be of less value or use. One way of maximizing the impact of this approach is
to survey youth and find out what prizes they see as desirable. A related way is
to ask youth who are offered the intervention what they might want to work
for and make sure that these items are available.
The last factor that must be considered is how long to continue to provide incentives for desirable behavior. Ultimately, youth need to internalize
the recovery process and find or develop naturally occurring reinforcers that
will support their recovery-based and nonaddict identities (Kellogg et al.,
2005; see also Lewis & Petry, 2005). Although FFT is designed to address
the underlying substance use disorder and promote the appropriate behavior
change needed for a lasting drug-free lifestyle within this time frame, a longer
period of contingency management would help make this happen.
Hollimon, Turner, Davidson, and Robbins (2012) demonstrated evidence for the effectiveness of FFT integrated with CM in a sample of 45 adolescents who received treatment after being referred by the juvenile courts
in New York City. All youth had a history of marijuana abuse, and, at baseline, 71% met substance abuse criteria of the Diagnostic and Statistical Manual
of Mental Disorders (4th ed.; [DSMIV]; American Psychiatric Association,
1994). Among those youth not meeting DSMIV diagnostic criteria at
baseline, 90% had at least one positive urine screen during treatment. The
sample also met other DSMIV diagnostic criteria: conduct, oppositional
defiant, or disruptive behavior disorder (94%); mood disorder (47%); and
attention-deficit/hyperactivity disorder (ADHD) (24%). Therapy was conducted by therapists from a large community agency in New York City (New
York Foundling). In this evaluation, FFT was enhanced with a CM protocol
that was introduced approximately 3 weeks into treatment and persisted to
the end of treatment, approximately eight weekly sessions on average. With
13190-14_Ch13_2ndPgs.indd 225
225
2/8/13 11:15 AM
respect to outcomes, a positive marijuana screen occurred for 61% of the

clients at the 1st CM week, 42% at the 4th CM week, and 26% by the 6th
CM week. The therapists rated the clinical outcomes as being positive for
approximately 70% of the clients. Both the families and the therapists had a
positive response to the CM procedure. Provisional findings suggest that the
cost savings from avoided outplacement (e.g., incarceration, foster care) are
expected to cover the added expenses of implementing CM with FFT.
FFT and Trauma
Many youth referred through mental health, school, or juvenile justice systems have experienced some kind of trauma. According to Kerig
and Becker (2010), these youth are at elevated risk for posttraumatic stress
disorder. Trauma inherently involves the entire family within a process of
bidirectional influence. Although the trauma experience may involve a specific event that happened to one or more family members, the effects ripple
through the entire family system. In formulating trauma-focused FFT, Kerig
and Alexander (2012) noted the work of Figley (1989) on family stress,
characterizing the effect of trauma as experienced simultaneously by family members, vicariously experienced by one through another, intrafamilially
when one family member traumatizes another, or chiasmally when one family
members PTSD has contagion effects on the others (Kerig & Alexander,
2012, pp. 205206). Moreover, Kerig and Alexander observed that even
when violence is not passed along, emotional numbing causes dysfunctional
patterns to develop in families as in, for example, the familiar characterization of dont talk, dont think, and dont feel.
Numerous studies have shown that involving the family contributes to
the effectiveness of evidence-based trauma treatment for youth (Deblinger,
Hathaway, Lippmann, & Steer, 1993; Feeny, Foa, Treadwell, & March, 2004)
and that the presence of parent support mediates child outcomes (Cohen &
Mannarino, 2000). Given the high prevalence of PTSD among delinquent
youth and the high rates of effectiveness of FFT within this population, the
flexibility and tailoring of FFT to meet the needs of individual family members likely enhances treatment outcomes for families affected by trauma. The
Behavior Change Phase of FFTTF focuses specifically on strategies that help
families heal from trauma.
The strategies used in the trauma-focused behavior change sessions integrate key elements of a number of evidenced-based treatments such as traumafocused CBT (Cohen & Hien, 2006); cognitive processing therapy (Chard,
2005; 2009); attachment, self-regulation, and competency (Blaustein &
Kinniburgh, 2010); and elements from Figleys (1989) family-based approach.
13190-14_Ch13_2ndPgs.indd 226
2/8/13 11:15 AM
Aspects of these models are adapted for families of youth with disruptive
behaviors and are delivered in the sequence and depth necessary to match and
meet the needs of individual families. Specific topics included in the Behavior
Change Phase may include normalization, affect regulation, communication,
cognitive processing, and integration. FFTTF has been implemented successfully with families referred through juvenile justice and is currently under
going pilot testing in preparation for a formal randomized clinical trial.
FFT in Child Welfare Settings
FFTCW is an innovative specialization of FFT theory, principles,
and intervention strategies for children, adolescents, and families served
in child welfare settings. FFTCW is an evidence-informed practice that is
based on FFT. As such, the core features of the model are relational, systemic,
cognitive, and behavioral. Several adaptations were made to the FFT model
to address the complex needs of children and families with a documented
history of abuse or neglect. At the organizational level, program developers
recognized that the cost of family therapy may be too high for it to be used
with all clients. Moreover, the complexity of evidence-based family therapy
requires a level of clinical sophistication that exceeds the skill level of many
case planners who serve youth and families in these settings. Thus, the first
adaptations involved developing (a) a lower cost, less intensive version of
FFT for low-risk clients that matched the skill level of case planners and
(b) a higher cost, more intensive version of FFT for higher risk clients. In
doing so, the primary goal was to improve functioning for all child welfare
clients by tailoring treatment to the clients needs. This approach created
an infrastructure to provide risk-sensitive, family-focused services. The integration of these interventions in a single continuum has the potential to
achieve greater effectiveness and economy in preventive services by delivering the most appropriate, most fiscally efficient, and least invasive or restrictive intervention in response to changing family dynamics and situations. A
second adaptation involved integrating a developmental focus to meet the
needs of youth across the entire age range (018 years). FFT is a relational
approach that matches interventions to the relational configurations of families. With delinquent or substance-abusing adolescents, this often involves
accommodating families in which youth have considerable power to engage
and motivate family members into treatment. However, with younger children in FFTCW, it is necessary to implement more parent-driven intervention strategies to build skills and create a family context in which youth can
flourish. A third adaptation involved expanding the primary treatment focus
from a target youth (e.g., delinquent adolescent) to all family members. This
13190-14_Ch13_2ndPgs.indd 227
227
2/8/13 11:15 AM
has involved developing treatment modules to address the mental health,

substance abuse, and behavioral needs of parents as well as children.
As in FFT, interventions in FFTCW are delivered in a phasic manner.
In the high-risk track, the phases are identical to standard FFT and consist
of Engagement, Motivation, Relational Assessment, Behavior Change, and
Generalization Phases. In the low-risk track, interventions are also delivered
in a phasic manner, but the phases are Engagement, Motivation, Support/
Monitor, and Generalization.
Interventionists (low-risk track) and therapists (high-risk track) are
expected to have a broad understanding of risk and protective factors and
to understand how to systematically address these factors in a deliberate and
planned sequence. Risk and protective factors are specific to the youths developmental stage (e.g., infant, toddler, childhood, adolescent) and social context
(e.g., parent, family, ecosystem). In some respects, the interventionists and therapists are expected to function as clinically informed developmental psychologists who have skills in many areas, including cognitive, social, and emotional
development; identity formation; and biological and physical development.
The Relational Assessment Phase in FFTCW is the same as the process in FFT. One distinction, however, is relatively increased attention to
the assessment of relational hierarchy that is particularly developmentally
relevant for younger children (012). Relational functions are assessed for
each dyadic relationship in a family. For younger children (06), the assessment of relational functions is informed by attachment theory.
In the high-risk track, behavior change interventions look similar but
include more of an emphasis on parenting skills (e.g., positive parent involvement and limit setting) with younger children and monitoring and super
vision with older youth. At the family level, interventions are similar to the
standard approach and include an emphasis on strengthening within-family
relationships through communication training, problem solving, and conflict
management. However, in FFTCW, the Behavior Change Phase commonly
includes the use of individualized parent-focused coping strategies such as
mood management, stress management, relaxation training, and building of
internal and external supports.
In the low-risk track, the Behavior Change Phase is replaced with the
Support/Monitor Phase. During the Support/Monitor Phase, the focus is on
identifying resources and interventions best suited to youth and families and
supporting links to those change programs. Interventionists are expected to
use their case management skills to maintain and enhance the impact of
evidence-based interventions on family members.
As in all of FFT, the Generalization Phase of FFTCW is a critical
component of the intervention process in both the low- and the high-risk
tracks. Generalization often begins concurrently with the Behavior Change
13190-14_Ch13_2ndPgs.indd 228
2/8/13 11:15 AM
or Support/Monitor Phase and builds until the end of treatment. In FFTCW,

the following areas are frequently targeted in the Generalization Phase: youth
and parent mental health and substance abuse, early intervention and educational services, and housing. Generalization Phase activities require close
coordination and frequent communication with youth and family management support systems: child welfare, mental health, justice, drug court, welfare, education, and so forth.
The promise of FFTCW was demonstrated in a pilot study involving
55 families that completed treatment at a community treatment agency in
New York City (Robbins & Rowlands, 2012). In this pilot evaluation, several
important findings emerged: 79% of low-risk and 71% of high-risk families
met all treatment goals, and an additional 17% of low-risk and 21% of highrisk families met at least one treatment goal. As expected, the months to close
for high-risk cases (M = 7.2, SD = 5.45) were somewhat higher (d = 0.28)
than for low-risk cases (M = 5.87, SD = 3.76). Moreover, 55% of high-risk
cases and 59% of low-risk cases were closed within 6 months, a rate that was
higher than that of comparable agencies in Manhattan (24%) or citywide
(22%). Finally, on the basis of a chart review, not a single case required an
out-of-home placement in the 12-month period following referral to FFT
CW services. Collectively, these findings demonstrate the promise of FFT
CW with low- and high-risk families.
FFT for Youth and Families Experiencing Depression
The point prevalence of major depressive disorder in older adolescents
is 2% to 5%, with lifetime rates approaching 20% (e.g., Lewinsohn, Hops,
Roberts, Seeley, & Andrews, 1993; McGee et al., 1990). Adolescent depressive episodes are often chronic or recurrent (e.g., Harrington, Fudge, Rutter,
Pickles, & Hill, 1990; Lewinsohn, Rohde, Seeley, & Baldwin, 2001; McCauley
et al., 1993) and have serious negative consequences, including impaired academic and occupational functioning, increased sexual activity, teenage pregnancy, and marital dissatisfaction (Kandel & Davies, 1986; Lewinsohn, Petit,
Joiner, & Seeley, 2003; Rao et al., 1995; Whitbeck, Conger, & Dao, 1993).
Approximately 20% to 30% of community adolescents with depression have
comorbid substance abuse (Armstrong & Costello, 2002; Kandel et al., 1997).
Whereas both depression and substance abuse result in numerous negative
consequences, their co-occurrence appears to be the single greatest risk factor for adolescent suicide attempt or completion (Aharonovich, Liu, Nunes,
& Hasin, 2002; Vermeiren et al., 2003). Comorbid depression and substance
use disorder is also associated with academic impairment, family dysfunction,
increased functional impairment, and HIV risk.
13190-14_Ch13_2ndPgs.indd 229
229
2/8/13 11:15 AM
Behavior change in families struggling with a member who has depression involves strategies to address family relationship functioning, such as
communication and problem-solving skills, as well as targeted interventions
for managing depression and other negative moods. Particular skills are trained
using a menu-driven process, integrating techniques used in evidence-based
treatments for depression in the literature. FFTDEP has relied heavily on the
evidence-based approach called coping with depression (Clarke, Lewinsohn,
& Hops, 1990). Specific topics may include mood monitoring, social skills,
relaxation training, pleasant events, and cognitive therapy sessions.
Social skills sessions focus on conversation techniques, planning for
social activities, and strategies for making friends. Social skills are spread
throughout the Behavior Change Phase to better integrate them with other
skills (e.g., pleasant activities). Relaxation sessions, which teach deep muscle
relaxation and breathing techniques, are taught fairly early in the Behavior
Change Phase because they are relatively easy to learn and provide family
members with an initial success experience, which may increase perceived
self-efficacy (Bandura, 1977), a critical component of successful interventions (e.g., Zeiss, Lewinsohn, & Munoz, 1979). In addition, family members
tend to find these techniques helpful in accomplishing other skills (e.g., social
activities). Pleasant events sessions are based on the hypothesis that low rates
of response-contingent positive reinforcement are a critical antecedent for
depression (Lewinsohn, Biglan, & Zeiss, 1975). Many depressed youth and
families have a limited repertoire of non-drug-related pleasant activities.
The cognitive therapy sessions are based on the hypothesis that depression is both caused and maintained by negative or irrational cognitive schemata. FFTDEP incorporates elements of interventions developed by Beck,
Kovacs, and Weissman (1979) and Ellis and Harper (1961) for identifying
and challenging negative and irrational thoughts. Through a series of progressively more advanced exercises, family members are taught to apply cognitive techniques to their own thinking with the goal of learning to generate
their own effective, positive counterarguments to negative beliefs. Family
members are also taught to correctly identify depressive symptoms so they
can appropriately address the triggers of depressed mood rather than focus on
their own reactions to the behavior. Communication skills training may be
expanded for depressed families by helping family members work together to
constructively interpret and correct negative behavior patterns.
Skills are introduced in a manner designed specifically to be in keeping
with the familys assessed functions and presenting problems. Thus, the same
skill may be implemented very differently in families with self-cutting, suicide attempts, and other intense behaviors than in families characterized more
by extreme sad affect, social withdrawal, and lethargy. The therapists focus is
on helping the family work together to develop skills. Because many parents
13190-14_Ch13_2ndPgs.indd 230
2/8/13 11:15 AM
of depressed youth also suffer from depression, the Behavior Change Phase
includes strategies to address negative moods as a family issue. For example, the
entire family, including nondepressed members, can participate in the identification of distorted thinking patterns, and all can participate in planning effective strategies for challenging these patterns when they occur at home.
Conclusion
If imitation is the highest form of flattery, we would like to believe
that specific specialized applications of the FFT model are a reflection of the
widespread and solid basis that FFT represents now and for the future. Each
of the specializations described in this chapter reflects requests from other
treatment systemssystems already familiar with and confident in the ability of the core FFT model to provide an effective and sustainable treatment
approach to diverse clinical challenges involving youth.
To conclude, the only caveat remaining is that of the need for all clinicians to do their homework. As clinicians apply FFT or any other treatment
strategy to new populations, we ask that they first develop knowledge of the
populations and syndromes involved. As noted in the beginning of this book,
FFT has always looked to more than mental health treatment resources for
knowledge regarding treatment populations: Sociology, psychiatry, anthropology, psychology, and literatures pertaining to gestalt theory and dynamic
systems theories together represent perspectives on what should be done in
any particular clinical situation. These perspectives are not equally relevant
to all cases, but it is the clinicians job to sort through the dynamics of each
specific clinical case to determine which balance of perspectives best serves
the clinical process. We have done that in FFT with respect to high-risk,
difficult-to-treat adolescents and their families, and we hope that as we have
described the result of this work, we have provided a service to a great and
diverse range of clinicians.
13190-14_Ch13_2ndPgs.indd 231
231
2/8/13 11:15 AM
13190-14_Ch13_2ndPgs.indd 232
2/8/13 11:15 AM
References
Abbott, R. D., ODonnell, J., Hawkins, J. D., Hill, K. G., Kosterman, R., & Catalano,
R. F. (1998). Changing teaching practices to promote achievement and bonding to school. American Journal of Orthopsychiatry, 68, 542552. doi:10.1037/
h0080363
Aharonovich, E., Liu, X., Nunes, E., & Hasin, D. S. (2002). Suicide attempts in
substance abusers: Effects of major depression in relation to substance use
disorders. American Journal of Psychiatry, 159, 16001602. doi:10.1176/appi.
ajp.159.9.1600
Alexander, J. F. (1971). Evaluation summary: Family groups treatment program [Report
to Juvenile Court, District 1]. Salt Lake City, UT: State of Utah.
Alexander, J. F. (1973). Defensive and supportive communications in normal and deviant families. Journal of Consulting and Clinical Psychology, 40, 223231. doi:10.1037/
h0034514
Alexander, J. F., & Barton, C. (1976). Behavioral systems therapy with families.
In D. H. Olson (Ed.), Treating relationships (pp. 167187). Lake Mills, IA:
Graphic.
Alexander, J. F., & Barton, C. (1980). Intervention with delinquents and their
families: Clinical, methodological, and conceptual issues. In J. Vincent (Ed.),
Advances in family intervention, assessment and theory (pp. 134142). Greenwich,
CT: JAI Press.
Alexander, J. F., Barton, C., Schiavo, R. S., & Parsons, B. V. (1976). Behavioral
intervention with families of delinquents: Therapist characteristics and outcome. Journal of Consulting and Clinical Psychology, 44, 656664. doi:10.1037/
0022-006X.44.4.656
Alexander, J. F., Barton, C., Waldron, H., & Mas, C. H. (1983). Beyond the technology of family therapy: The anatomy of intervention model. In K. D. Craig &
R. H. McMahon (Eds.), Advances in clinical behavior therapy (pp. 4873). New
York, NY: Brunner/Mazel.
Alexander, J. F., & Parsons, B. V. (1973). Short-term behavioral intervention with
delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219225. doi:10.1037/h0034537
Alexander, J. F., & Parsons, B. V. (1982). Functional Family Therapy: Principles and
procedures. Carmel, CA: Brooks/Cole. doi:10.1037/11621-000
Alexander, J. F., Pugh, C., & Parsons, B. V. (1998). Blueprints for Violence Prevention. Boulder, CO: Venture.
Alexander, J. F., Waldron, H. B., Barton, C., & Mas, C. H. (1989). Minimizing blaming attributions and behavior in conflicted delinquent families.
Journal of Consulting and Clinical Psychology, 57, 1924. doi:10.1037/0022006X.57.1.19
233
13190-15_Reference_2ndPgs.indd 233
2/8/13 11:14 AM
Alverado, R., Kendall, K., Beesley, S., & Lee-Cavaness, C. (2000). Strengthening
Americas families: Model family program for substance abuse and delinquency prevention. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.) Washington, DC: Author.
Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of
prevention and early intervention programs for youth: Technical appendix. Olympia,
WA: Washington State Institute for Public Policy.
Aos, S., Phipps, P., Barnoski, R., & Lieb, R. (2001). The comparative costs and benefits
of programs to reduce crime. Olympia, WA: Washington State Institute for Public
Policy.
Aponte, H. J., & Van Deusen, J. H. (1981). Structural family therapy. In A. S. Gurman
& D. P. Kniskern (Eds.), Handbook of family therapy (pp. 310359). New York, NY:
Brunner/Mazel.
Armstrong, T. D., & Costello, E. J. (2002). Community studies on adolescent
substance use, abuse, or dependence and psychiatric comorbidity. Journal of
Clinical and Community Psychology, 70, 12241239.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice Hall.
Barnoski, R. (2002). Washington States implementation of Functional Family Therapy
for juvenile offenders: Preliminary findings. Olympia, WA: Washington State Institute for Public Policy.
Barton, C., & Alexander, J. F. (1981). Functional family therapy. In A. S. Gurman
& D. P. Kniskern (Eds.), Handbook of family therapy (pp. 403443). New York,
NY: Brunner/Mazel.
Barton, C., Alexander, J. F., & Turner, C. W. (1988). Defensive communications in
normal and delinquent families: The impact of context and family role. Journal
of Family Psychology, 1, 390405. doi:10.1037/h0080468
Barton, C., Alexander, J. F., Waldron, H., Turner, C. W., & Warburton, J. (1985).
Generalizing treatment effects of Functional Family Therapy: Three replications.
American Journal of Family Therapy, 13, 1626.
Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention:
The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47,
343352. doi:10.1037/0022-006X.47.2.343
Bellg, A. J., Borrelli, B. B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M.,...
Czajkowski, S., & the Treatment Fidelity Workgroup of the NIH Behavior
Change Consortium. (2004). Enhancing treatment fidelity in health behavior
change studies: Best practices and recommendations from the NIH Behavior Change Consortium. Health Psychology, 23, 443451. doi:10.1037/02786133.23.5.443
234 references
2/8/13 11:14 AM
Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing source.
Psychological Review, 88, 354364. doi:10.1037/0033-295X.88.4.354
Benjamin, L. S. (1993). Interpersonal diagnosis and treatment of personality disorders.
New York, NY: Guilford Press.
Berk, L. (2000). Development through the lifespan (2nd ed.). Boston, MA: Allyn &
Bacon.
Blakely, C., Mayer, J., Gottschalk, R., Schmitt, N., Davidson, W., Roitman, D., &
Emshoff, J. (1987). The fidelityadaptation debate: Implications for the implementation of public sector social programs. American Journal of Community Psychology,
15, 253268. doi:10.1007/BF00922697
Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children
and adolescents: How to foster resilience through attachment, self-regulation, and
competency. New York, NY: Guilford Press.
Botvin, G. J., Malgady, R. G., Griffin, K. W., Scherer, L. M., & Epstein, J. A.
(1998). Alcohol and marijuana use among rural youth: Interaction of social
and intrapersonal influences. Addictive Behaviors, 23, 379387. doi:10.1016/
S0306-4603(98)00006-9
Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513531. doi:10.1037/0003-066X.32.7.513
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature
and design. Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1986). Ecology of the family as a context for human development.
Developmental Psychology, 22, 723742.
Brooks, A., Janer, N., Early, K., & Mason, K. (2012, April). The key ingredients for
sustaining Functional Family Therapy services in Florida. Paper presented at the
Annual Blueprints for Violence Prevention Conference, San Antonio, TX.
Byrnes, H. F., Miller, B. A., Aalborg, A. E., Plasencia, A. V., & Keagy, C. D. (2010).
Implementation fidelity in adolescent family-based prevention programs:
Relationship to family engagement. Health Education Research, 25, 531541.
doi:10.1093/her/cyq006
Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S., Pope, K. S.,
Crits-Christoph, P.,...McCurry, S. (1996). An update on empirically validated
therapies. Clinical Psychologist, 49, 518.
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse.
Chard, K. M. (2009, December). Cognitive processing therapy for sexual abuse. Training
conducted at the Mayerson Center for Safe and Healthy Families, Cincinnati
Childrens Hospital, Cincinnati, OH.
references
235
2/8/13 11:14 AM
Clarke, G. N., Lewinsohn, P. M., & Hops, H. (1990). The Adolescent Coping With
Depression Course: A psychoeducational intervention for unipolar depression in high
school students. Eugene, OR: Castalia Press.
Cohen, J. A., & Mannarino, A. P. (2000). Predictors of treatment outcome in sexually abused children. Child Abuse & Neglect, 24, 983994. doi:10.1016/S01452134(00)00153-8
Cohen, L. R., & Hien, D. A. (2006). Treatment outcomes for women with substance
abuse and PTSD who have experienced complex trauma. Psychiatric Services,
57, 100106. doi:10.1176/appi.ps.57.1.100
Coles, J. L., Alexander, J. F., & Schiavo, R. S. (1974, October). A developmental model
of family systems: A socialpsychological approach. Paper presented at the Theory
Construction Workshop, National Council of Family Relations, St. Louis, MO.
Curtis, N. M., Ronan, K. R., & Borduin, C. M. (2004). Multisystemic treatment:
A meta-analysis of outcome studies. Journal of Family Psychology, 18, 411419.
doi:10.1037/0893-3200.18.3.411
Davey, G. C. (1992). Classical conditioning and the acquisition of human fears and
phobias: A review and synthesis of the literature. Advances in Behaviour Research
& Therapy, 14, 2966. doi:10.1016/0146-6402(92)90010-L
Deblinger, E., Hathaway, C. R., Lippmann, J., & Steer, R. (1993). Psychosocial
characteristics and correlates of symptom distress in nonoffending mothers
of sexually abused children. Journal of Interpersonal Violence, 8, 155168.
doi:10.1177/088626093008002001
DZurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107126. doi:10.1037/h0031360
Elliott, D. S. (1997). Blueprints for Violence Prevention (Vols. 12). Boulder: University
of Colorado, Center for the Study and Prevention of Violence.
Elliott, D. S. (Series Ed.). (1998). Blueprints for Violence Prevention. Boulder:
Blueprints, University of Colorado, Center for the Study and Prevention of
Violence.
Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating
effective prevention programs. Prevention Science, 5, 4753. doi:10.1023/
B:PREV.0000013981.28071.52
Ellis, A., & Harper, R. A. (1961). A guide to rational living. Hollywood, CA: Wilshire
Books.
Embry, D. D., & Biglan, A. (2008). Evidence-based kernels: Fundamental units of
behavioral influence. Clinical Child and Family Psychology Review, 11, 75113.
doi:10.1007/s10567-008-0036-x
Erickson, M. H., & Rossi, E. L. (1976). Two-level communication and the microdynamics of trance and suggestion. American Journal of Clinical Hypnosis, 18,
153171. doi:10.1080/00029157.1976.10403794
Feeny, N. C., Foa, E. B., Treadwell, K. R., & March, J. (2004). Posttraumatic stress
disorder in youth: A critical review of the cognitive and behavioral treatment
236 references
2/8/13 11:14 AM
outcome literature. Professional Psychology: Research and Practice, 35, 466476.

doi:10.1037/0735-7028.35.5.466
Fiedler, F. E., Chemers, M. M., & Mahar, L. (1976). Improving leadership effectiveness:
The leader match concept. New York, NY: Wiley.
Figley, C. R. (1989). Helping traumatized families. San Francisco, CA: Jossey-Bass.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005).
Implementation research: A synthesis of the literature (FMHI Publication No. 231).
Tampa, FL: National Implementation Research Network, University of South
Florida, Louis de la Parte Florida Mental Health Institute.
Flicker, S. M., Waldron, H. B., Turner, C. W., Brody, J. L., & Hops, H. (2008). Ethnic
matching and treatment outcome with Hispanic and Anglo substance-abusing
adolescents in family therapy. Journal of Family Psychology, 22, 439447.
Forgatch, M. S., Patterson, G. R., & DeGarmo, D. S. (2005). Evaluating fidelity:
Predictive validity for a measure of competent adherence to the Oregon model
of parent management training. Behavior Therapy, 36, 313. doi:10.1016/
S0005-7894(05)80049-8
Freitag, M. J., Alexander, J. F., & Turner, C. W. (2010). Parentadolescent alliances as
a predictor of retention in functional family therapy (Unpublished masters thesis).
University of Utah, Salt Lake City.
French, M. T., Zavala, S. K., McCollister, K. E., Waldron, H. B., Turner, C. W., &
Ozechowski, T. J. (2008). Cost effectiveness analysis (CEA) of four interventions for adolescents with a substance use disorder. Journal of Substance Abuse
Treatment, 34, 272281. doi:10.1016/j.jsat.2007.04.008
Friedman, A. S. (1989). Family therapy vs. parent groups: Effects on adolescent
drug abusers. American Journal of Family Therapy, 17, 335347. doi:10.1080/
01926188908250780
Fuller, B. E., Rieckmann, T., Nunes, E. V., Miller, M., Arfken, C., Edmundson, E., &
McCarty, D. (2007). Organizational readiness for change and opinions toward
treatment innovations. Journal of Substance Abuse Treatment, 33, 183192.
doi:10.1016/j.jsat.2006.12.026
Function. (2012). In Merriam-Websters online dictionary. Retrieved from http://www.
merriam-webster.com/dictionary/function
Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why dont we see more
translation of health promotion research to practice? Rethinking the efficacyto-effectiveness transition. American Journal of Public Health, 93, 12611267.
doi:10.2105/AJPH.93.8.1261
Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health
impact of health promotion interventions: The RE-AIM Framework. American
Journal of Public Health, 89, 13221327. doi:10.2105/AJPH.89.9.1322
Gordon, D. A. (1995). Functional Family Therapy for delinquents. In R. R. Ross,
D. H. Antonowics, & G. K. Dhaliwal (Eds.), Going straight: Effective delinquency
prevention and offender rehabilitation (pp. 163178). Ottawa, Ontario, Canada:
Air Training.
references
237
2/8/13 11:14 AM
Gordon, D. A., & Arbuthnot, J. (1990). Individual family and group interventions.
In H. C. Quay (Ed.), Handbook of juvenile delinquency (pp. 290324). New York,
NY: Wiley.
Gordon, D. A., Arbuthnot, J., Gustafson, K. E., & McGreen, P. (1988). Home-based
behavioural-systems family therapy with disadvantaged juvenile delinquents.
American Journal of Family Therapy, 16, 243255. doi:10.1080/019261888
08250729
Gordon, D. A., Graves, K., & Arbuthnot, J. (1995). The effect of Functional Family
Therapy for delinquents on adult criminal behavior. Criminal Justice and Behavior,
22, 6073. doi:10.1177/0093854895022001005
Gurman, A. S., Kniskern, D. P., & Pinsof, W. M. (1986). Research on the process
and outcome of marital and family therapy. In S. L. Garfield & A. E. Bergin
(Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 565624).
New York, NY: Wiley.
Gustafson, K., Gordon, D. A., & Arbuthnot, J. (1985, Spring). A costbenefit analysis
of in-home family therapy vs. probation for juvenile delinquents. Paper presented at
the annual Banff Conference on Behavioral Sciences, Banff, Alberta, Canada.
Haley, J. (1963). Strategies of psychotherapy. New York, NY: Grune & Stratton.
Haley, J. (1976). Problem solving therapy. San Francisco, CA: Jossey-Bass.
Hall, G. S. (1904). Adolescence: Its psychology and its relations to physiology,
anthropology, sociology, sex, crime, religion and education. Classics in the History
of Psychology, 2. Retrieved from http://psychclassics.asu.edu/Hall/Adolescence/
chap17.htm.
Hansson, K., Cederblad, M., & Hk, B. (2000). Funktionell Familjeterapien
behandlingsmetod vid ungdomskriminalitet [Functional family therapy: A
method for treating juvenile delinquents]. Socialvetenskaplig Tidskrift, 3, 231243.
Hansson, K., Johansson, P., Drott-Engln, G., & Benderix, Y. (2004). Funktionell
familjeterapi i barnpsykiatrisk praxis: Om behandling av ungdomskriminalitet
utanfor universitesforskningen [Functional Family Therapy in child psychiatric
practice: On the treatment of youth criminality outside of university research].
Nordisk Psykologi, 56, 304320.
Harrington, R., Fudge, H., Rutter, M., Pickles, A., & Hill, J. (1990). Adult outcomes
of childhood and adolescent depression: I. Psychiatric status. Archives of General
Psychiatry, 47, 465473. doi:10.1001/archpsyc.1990.01810170065010
Hawkins, J. D., Catalano, R. F., Jr., & Associates. (1992). Communities that care:
Action for drug abuse prevention. San Francisco, CA: Jossey-Bass.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood:
Implications for substance abuse prevention. Psychological Bulletin, 112, 64105.
doi:10.1037/0033-2909.112.1.64
Heidegger, M. (1962). Being and time (J. Macquarrie & E. Robinson, Trans.). New York,
NY: Harper & Row. (Original work published 1927)
238 references
2/8/13 11:14 AM
Henggeler, S. W., Clingempeel, W. G., Brondino, M. J., & Pickrel, S. G. (2002). Fouryear follow-up of multisystemic therapy with substance-abusing and substancedependent juvenile offenders. Journal of the American Academy of Child & Adolescent
Psychiatry, 41, 868874. doi:10.1097/00004583-200207000-00021
Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H.
(1997). Multisystemic therapy with violent and chronic juvenile offenders
and their families: The role of treatment fidelity in successful dissemination.
Hogue, A., Dauber, S., Chinchilla, P., Fried, A., Henderson, C., Inclan, J.,...Liddle,
H. A. (2008). Assessing fidelity in individual and family therapy for adolescent substance abuse. Journal of Substance Abuse Treatment, 35, 137147.
doi:10.1016/j.jsat.2007.09.002
Hollimon, A., Turner, C. W., Davidson, K., & Robbins, M. S. (2012, August).
Quality assurance and quality improvement with the FFT drug abuse contingency
management module. Paper presented at the annual convention of the American
Psychological Association, Orlando, FL.
Hops, H., Ozechowski, T. J., Waldron, H. B., Davis, B., Turner, C. J., Brody, J., &
Barrera, M. (2011). Adolescent health-risk sexual behaviors: Effects of a drug
abuse intervention. AIDS and Behavior, 15, 16641676.
Jensen, K. (2008). Relational vs. individual focus in family therapy sessions (Unpublished
senior thesis). Department of Psychology, University of Utah, Salt Lake City.
Joe, G. W., Broome, K. M., Simpson, D. D., & Rowan-Szal, G. A. (2007). Counselor perceptions of organizational factors and innovations training experiences.
Journal of Substance Abuse Treatment, 33, 171182.
Kandel, D. B., & Davies, M. (1986). Adult sequelae of adolescent depressive
symptoms. Archives of General Psychiatry, 43, 255262. doi:10.1001/archpsyc.
1986.01800030073007
Kandel, D. B., Johnson, J. G., Bird, H. R., Canino, G., Goodman, S. H., Lahey,
B. B.,...Schwab-Stone, M. (1997). Psychiatric disorders associated with substance use among children and adolescents: Finding from the methods for the
epidemiology of child and adolescent mental disorders (MECA) study. Journal
of Abnormal Child Psychology, 25, 121132. doi:10.1023/A:1025779412167
Kazdin, A. E. (1990). Premature termination from treatment among children referred
for antisocial behavior. Journal of Child Psychology and Psychiatry, 31, 415425.
doi:10.1111/j.1469-7610.1990.tb01578.x
Kazdin, A. E. (2005). Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. New York, NY: Oxford
University Press.
Kazdin, A. E., Mazurick, J. L., & Siegel, T. C. (1994). Treatment outcome among
children with externalizing disorder who terminate prematurely versus those
who complete psychotherapy. Journal of the American Academy of Child & Adolescent Psychiatry, 33, 549557.
references
239
2/8/13 11:14 AM
Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M. L., Wale, J. B., & Kreek, M. J.
(2005). Something of value: The introduction of contingency management
interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, 5765. doi:10.1016/
j.jsat.2004.10.007
Kerig, P. K., & Alexander, J. F. (2012). Family matters: Integrating trauma treatment into Functional Family Therapy for delinquent youth. Journal of Child &
Adolescent Trauma, 5, 205223.
Kerig, P. K., & Becker, S. P. (2010). From internalizing to externalizing: Theoretical
models of the processes linking PTSD to juvenile delinquency. In S. J. Egan (Ed.),
Posttraumatic stress disorder (PTSD): Causes, symptoms and treatment (pp. 3378).
Hauppauge, NY: Nova Science.
Kinney, J. M., Madsen, B., Fleming, T., & Haapala, D. (1977). Homebuilders: Keeping families together. Journal of Consulting and Clinical Psychology, 45, 667673.
doi:10.1037/0022-006X.45.4.667
Klein, N. C., Alexander, J. F., & Parsons, B. V. (1977). Impact of family systems
intervention on recidivism and sibling delinquency: A model of primary prevention and program evaluation. Journal of Consulting and Clinical Psychology,
45, 469474. doi:10.1037/0022-006X.45.3.469
Kopp, D., & Medina, J. (2009). Functional Family Probation services (Unpublished
treatment manual). Seattle, WA: FFT.
La Greca, A. M., Silverman, W. K., & Lochman, J. E. (2009). Moving beyond efficacy and effectiveness in child and adolescent intervention research. Journal of
Consulting and Clinical Psychology, 77, 373382. doi:10.1037/a0015954
Lantz, B. L. (1982). Preventing adolescent placement through Functional Family Therapy
and tracking (Grant No. CDP 1070 UT 83-0128020 87-6000-545-W). Kearns,
UT: Utah Department of Social Services.
Lazarus, A. (1996). Behavior therapy & beyond. New York, NY: Jason Aronson.
Lazarus, R. S. (1966). Psychological stress and the coping process. New York, NY:
McGraw-Hill.
Leary, T. (1957). Interpersonal diagnosis of personality. New York, NY: Ronald Press.
Lewinsohn, P. M., Biglan, A., & Zeiss, A. M. (1975). Behavior treatment of depression. In P. Davidson (Ed.), Behavioral management of anxiety, depression, and pain
(pp. 91146). New York, NY: Brunner/Mazel.
Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews, J. A. (1993).
Adolescent psychopathology: I. Prevalence and incidence of depression and
other DSMIIIR disorders in high school students. Journal of Abnormal Psychology, 102, 133144. doi:10.1037/0021-843X.102.1.133
Lewinsohn, P. M., Petit, J., Joiner, T. E., Jr., & Seeley, J. R. (2003). The symptomatic
expression of major depressive disorder in adolescents and young adults. Journal
of Abnormal Psychology, 112, 244252. doi:10.1037/0021-843X.112.2.244
240 references
2/8/13 11:14 AM
Lewinsohn, P. M., Rohde, P., Seeley, J. R., & Baldwin, C. L. (2001). Gender differences
in suicide attempts from adolescence to young adulthood. Journal of the American
Academy of Child & Adolescent Psychiatry, 40, 427434. doi:10.1097/00004583200104000-00011
Lewis, M. W., & Petry, N. M. (2005). Contingency management treatments that
reinforce completion of goal-related activities: Participation in family activities
and its association with outcomes. Drug and Alcohol Dependence, 79, 267271.
doi:10.1016/j.drugalcdep.2005.01.016
Lewis, R. A., Piercy, F. P., Sprenkle, D. H., & Trepper, T. S. (1990). Family-based
interventions for helping drug-abusing adolescents. Journal of Adolescent Research,
5, 8295. doi:10.1177/074355489051008
Liddle, H. A. (1991). Training and supervision in family therapy: A comprehensive
and critical analysis. In A. Gurman & D. Kniskern (Eds.), Handbook of family
therapy (Vol. 2, pp. 638697). Philadelphia, PA: Brunner/Mazel.
Liddle, H. A., Rowe, C. L., Dakof, G. A., Ungaro, R. A., & Henderson, C. E. (2004).
Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs, 36, 4963.
doi:10.1080/02791072.2004.10399723
Liddle, H. A., Rowe, C. L., Gonzalez, A., Henderson, C. E., Dakof, G. A., &
Greenbaum, P. E. (2006). Changing provider practices, program environment,
and improving outcomes by transporting Multidimensional Family Therapy to
an adolescent drug treatment setting. American Journal on Addictions, 15(Suppl. 1),
102112. doi:10.1080/10550490601003698
Liddle, N. (1989). Therapist humor and client positive attitude in family therapy (Unpublished masters thesis). University of Utah, Salt Lake City.
Malouf, R. E., & Alexander, J. F. (1974). Family crisis intervention: A model and
technique of training. In R. E. Hardy & J. G. Cull (Eds.), Therapeutic needs of the
family (pp. 4755). Springfield, IL: Charles C Thomas.
Mas, C. H., Alexander, J. F., & Barton, C. (1985). Modes of expression in family therapy: A process study of roles and gender. Journal of Marital and Family Therapy,
11, 411415.
Maslow, A. (1943). A theory of human motivation. Psychological Review, 50, 370396.
McCauley, E., Myers, K., Mitchell, J., Calderon, R., Schloredt, K., & Treder, R.
(1993). Depression in young people: Initial presentation and clinical course.
Journal of the American Academy of Child & Adolescent Psychiatry, 32, 714722.
doi:10.1097/00004583-199307000-00003
McGee, R., Feehan, M., Williams, S., Partridge, F., Silva, P. A., & Kelly, J. (1990).
DSMIII disorders in a large sample of adolescents. Journal of the American
Academy of Child & Adolescent Psychiatry, 29, 611619. doi:10.1097/00004583199007000-00016
references
241
2/8/13 11:14 AM
McHugh, R. K., Murray, H. W., & Barlow, D. H. (2009). Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise
of transdiagnostic interventions. Behaviour Research and Therapy, 47, 946953.
doi:10.1016/j.brat.2009.07.005
Metz, A. J. R., Blas, K. A., Fixsen, D. L., & Van Dyke, M. (2009, November). Implementation and systems change to support effective service. Paper presented at the
Bridging the Gap: Research, Practice, and Policy Symposium, Fort Worth, TX.
Mihalic, S., & Irwin, K. (2003). Blueprints for Violence Prevention: From research
to real world settingsFactors influencing the successful replication of model
programs. Youth Violence and Juvenile Justice, 1, 123.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA:
Harvard University Press.
Morris, S. M., Alexander, J. F., & Turner, C. W. (1991). Do reattributions reduce
blame? Journal of Family Psychology, 5, 192203. doi:10.1037/0893-3200.5.2.192
Nathan, P. E., & Gorman, J. M. (2002). Efficacy, effectiveness, and the clinical utility of psychotherapy research. In P. E. Nathan & J. M. Gorman (Eds.), A guide to
treatments that work (2nd ed., pp. 642654). New York, NY: Oxford University
Press.
Newberry, A. M., Alexander, J. F., & Turner, C. W. (1991). Gender as a process variable in family therapy. Journal of Family Psychology, 5, 158175. doi:10.1037/
0893-3200.5.2.158
ODell, S. (1974). Training parents in behavior modification: A review. Psychological
Bulletin, 81, 418433. doi:10.1037/h0036545
Parsons, B. V., & Alexander, J. F. (1973). Short term family intervention: A therapy outcome study. Journal of Consulting and Clinical Psychology, 41, 195201.
doi:10.1037/h0035181
Patterson, G. R. (1971). Behavioral intervention procedures in the classroom and
in the home. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy
and behavior change: An empirical analysis (pp. 751755). New York, NY: Wiley.
Patterson, G. R. (1975). Families: Application of social learning to family life. Champaign, IL: Research Press.
Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia.
Patterson, G. R. (2002). Etiology and treatment of child and adolescent antisocial
behavior. Behavior Analyst Today, 3, 133144.
Patterson, G. R., & Reid, J. B. (1970). Reciprocity and coercion: Two facets of social
systems. In C. Neuringer & J. L. Michael (Eds.), Behavior modification in clinical
psychology (pp. 133177). New York, NY: Appleton-Century-Crofts.
Petry, N. M. (2000). A comprehensive guide to the application of contingency management procedures in clinical settings. Drug & Alcohol Dependence, 58(12),
925.
242 references
2/8/13 11:14 AM
Pirotta, S., & Cecchin, G. (1988). The Milan training program. In H. A. Liddle, D. C.
Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy training and supervision (pp. 3861). New York, NY: Guilford Press.
Rao, U., Ryan, N. D., Birmaher, B., Dahl, R. E., Williamson, D. E., Kaufman,
J.,...Nelson, B. (1995). Unipolar depression in adolescents: Clinical outcome
in adulthood. Journal of the American Academy of Child & Adolescent Psychiatry,
34, 566578. doi:10.1097/00004583-199505000-00009
Regas, S., & Sprenkle, D. (1982, October). Functional Family Therapy with hyper
active adolescents. Paper presented at the meeting of the American Association
for Marital and Family Therapy, Dallas, TX.
Reid, J. B., Patterson, G. R., & Snyder, J. (Eds.). (2002). Antisocial behavior in children
and adolescents: A developmental analysis and model for intervention. Washington,
DC: American Psychological Association. doi:10.1037/10468-000
Robbins, M. S., Alexander, J. F., Newell, R. M., & Turner, C. W. (1996). The immediate effect of reframing on client attitude in family therapy. Journal of Family
Psychology, 10, 2834. doi:10.1037/0893-3200.10.1.28
Robbins, M. S., Alexander, J. F., & Turner, C. W. (2000). Disrupting defensive
family interactions in family therapy with delinquent youth. Journal of Family
Psychology, 14, 688701. doi:10.1037/0893-3200.14.4.688
Robbins, M. S., Hollimon, A., Alexander, J. F., Mason, K., Armey, K., & Neeb, A.
(2011). The process of supervision in Functional Family Therapy. Unpublished
manual.
Robbins, M. S., & Rowlands, S. (2012, April). Using data to improve implementation
outcomes and sustainability. Paper presented at the Annual Blueprints for Violence
Prevention Conference, San Antonio, TX.
Robbins, M. S., Turner, C. W., Alexander, J. F., Liddle, H. A., & Szapocznik, J.
(2012). The unique contributions of common factors in family therapy for adolescent
substance users. Manuscript in preparation.
Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A. (2003). Alliance and
dropout in family therapy with drug using adolescents: Individual and systemic
effects. Journal of Family Psychology, 17, 534544. doi:10.1037/0893-3200.17.4.534
Robbins, M. S., Waldron, H. B., Hops, H., Turner, C. W., Ozechowski, T., Brody, J. L.,
& Alexander, J. F. (2011). Building outcomes with observation-based supervision:
An FFT effectiveness trial (National Institute on Drug Abuse Grant No. R01 DA
029406). Unpublished data.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Rohde, P., Waldron, H. B., Turner, C. W., Brody, J. L., & Jorgensen, J. (2012). Sequenced
versus integrated treatment for adolescents with comorbid depressive and substance use
disorders. Unpublished manuscript.
Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidencebased medicine: How to practice and teach EBM (2nd ed.). New York, NY:
Churchill Livingstone.
references
243
2/8/13 11:14 AM
Saldana, L., Chapman, J. E., Henggeler, S. W., & Rowland, M. D. (2007). The
Organizational Readiness for Change Scale in adolescent programs: Criterion validity. Journal of Substance Abuse Treatment, 33, 159169. doi:10.1016/
j.jsat.2006.12.029
Sciutto, M. J., Nolfi, C. J., & Bluhm, C. (2004). Effects of child gender and symptom
type on referrals for ADHD by elementary school teachers. Journal of Emotional
and Behavioral Disorders, 12, 247253. doi:10.1177/10634266040120040501
Sexton, T., & Turner, C. W. (2010). The effectiveness of functional family therapy
for youth with behavioral problems in a community practice setting. Journal of
Family Psychology, 24, 339348. doi:10.1037/a0019406
Sexton, T. L. (2010). Functional Family Therapy in clinical practice: An evidence-based
treatment model for working with troubled adolescents. Abingdon, England: Routledge.
Sexton, T. L., Alexander, J. F., & Mease, A. L. (2004). Change models and mechanisms in couple and family therapy. In M. Lambert (Ed.), Handbook of psychotherapy and behavior change (pp. 590646). New York, NY: Wiley.
Sherman, J. E., Jorneby, D. E., & Baker, T. B. (1988). Classical conditioning with
alcohol: Acquired preferences and aversions, tolerance, and urges/cravings. In
C. D. Chaudron & D. A. Wilkinson (Eds.), Theories on alcoholism (pp. 173287).
Toronto, Ontario, Canada: Addiction Research Foundation.
Sholomskas, D. E., Syracuse, G., Ball, S. A., Rounsaville, B. J., & Carroll, K. M.
(2005). We dont train in vain: A controlled trial of three strategies of training
clinicians in cognitivebehavioral therapy. Journal of Consulting and Clinical
Psychology, 73, 106115. doi:10.1037/0022-006X.73.1.106
Simpson, D. D. (2004). A conceptual framework for drug treatment process and
outcomes. Journal of Substance Abuse Treatment, 27, 99121. doi:10.1016/
j.jsat.2004.06.001
Simpson, D. D., & Flynn, P. M. (Eds.). (2007). Organizational readiness for
change [Special issue]. Journal of Substance Abuse Treatment, 33. doi:10.1016/
j.jsat.2006.12.023
Singh, I. (2008, December). Beyond polemics: Science and ethics of ADHD. Nature
Reviews Neuroscience, 9, 957964. doi:10.1038/nrn2514
Skinner, B. F. (1957). Verbal behavior. New York, NY: Appleton-Century-Crofts.
doi:10.1037/11256-000
Skinner, B. F. (1974). About behaviorism. New York, NY: Random House.
Skinner, B. F. (1981, July 31). Selection by consequences. Science, 213, 501504.
Slesnick, N., & Prestopnik, J. L. (2009). Comparison of family therapy outcome with
alcohol-abusing, runaway adolescents. Journal of Marital and Family Therapy, 35,
255277. doi:10.1111/j.1752-0606.2009.00121.x
Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition, and family/couples
treatment for drug abuse: A review of the controlled, comparative studies. Psycho
logical Bulletin, 122, 170191. doi:10.1037/0033-2909.122.2.170
244 references
3/11/13 2:02 PM
Storm, C. L., McDowell, T., & Long, J. K. (2003). The metamorphosis of training
and supervision. In T. L. Sexton, G. Weeks, & M. S. Robbins (Eds.), Handbook
of family therapy (Vol. 3, pp. 431446). New York, NY: Brunner Routledge.
Stuart, R. B. (1971). Behavioral contracting within the families of delinquents. Journal of Behavior Therapy and Experimental Psychiatry, 2, 111. doi:10.1016/00057916(71)90004-8
Vermeiren, R., Schwab-Stone, M., Ruchkin, V. V., King, R. A., Van Heeringen, C.,
& Deboutte, D. (2003). Suicidal behavior and violence in male adolescents:
A school-based study. Journal of the American Academy of Child & Adolescent
Psychiatry, 42, 4148. doi:10.1097/00004583-200301000-00009
Waldron, H. B., & Brody, J. (2010). Functional Family Therapy for adolescent
substance use disorders. In J. Weisz & A. Kazdin (Eds.), Evidence-based psycho
therapies for children and adolescents (2nd ed., pp. 401415). New York. NY:
Guilford Press.
Waldron, H. B., Brody, J., Turner, C. W., & Ozechowski, T. J. (2012). Functional
Family Therapy and cognitive behavioral treatments for adolescent alcohol misuse: A
randomized clinical trial. Unpublished manuscript.
Waldron, H. B., Brody, J. L., Turner, C. W., Ozechowski, T. J., & Hops, H. (2008).
Adolescent substance abuse: Progressive treatment (National Institute on Drug Abuse
Grant No. R01 DA023568). Unpublished data.
Waldron, H. B., Hops, H., Brody, J., Turner, C. W., Davis, B., & Barrera, M. (2012).
Family-based and individual cognitive behavioral treatments for Hispanic and Anglo
drug-abusing youth. Unpublished manuscript.
Waldron, H. B., Ozechowski, T. J., Brody, J., & Turner, C. W. (2012). Functional Family
Therapy and cognitive behavior therapies for adolescent substance abuse and delinquency:
Treatment outcomes and family mechanisms of change. Unpublished manuscript.
Waldron, H. B., Ozechowski, T. J., Brody, J., Turner, C. W., Hops, H., & Scherer, D.
(2012). Intensive in-home family systems intervention, clinic-based group therapy,
and telephone-based counseling: A comparison of three transitional continuing care
interventions following Functional Family Therapy for adolescent substance abuse.
Unpublished manuscript.
Waldron, H. B., Robbins, M. S., & Alexander, J. F. (2012, September). Functional
Family Therapy: A summary of treatment outcome research from 1971 through
2011. Retrieved from Oregon Research Institute website: http://www.ori.org/
scientists/holly_waldron
Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R.
(2001). Treatment outcomes for adolescent substance abuse at 4- and 7-month
assessments. Journal of Consulting and Clinical Psychology, 69, 802813.
doi:10.1037/0022-006X.69.5.802
Waldron, H. B., & Turner, C. W. (2008). Evidence-based psychosocial treatments
for adolescent substance abuse: A review and meta-analyses. Journal of Clinical
Child and Adolescent Psychology, 37, 124.
references
245
2/8/13 11:14 AM
Warburton, J., Alexander, J. F., & Barton, C. (1980, August). Sex of client and sex of
therapist: Variables in family process study. Paper presented at the annual convention of the American Psychological Association, Montreal, Quebec, Canada.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York,
NY: Norton.
Webster-Stratton, C., & Herbert, M. (1993). What really happens in parent training.
Behavior Modification, 17, 407456.
Whitbeck, L. B., Conger, R. D., & Dao, M.-Y. (1993). The influence of parental
support, depressed affect, and peers on the sexual behaviors of adolescent girls.
Journal of Family Issues, 14, 261278. doi:10.1177/019251393014002006
Witkiewitz, K. A., & Marlatt, G. A. (2007). Overview of relapse prevention. In
K. A. Witkiewitz & G. A. Marlatt (Eds.), Therapists guide to evidence-based
relapse prevention (pp. 317). London, England: Academic Press.
Woody, S. R., Weisz, J., & McLean, C. (2005). Empirically supported treatments:
10 years later. Clinical Psychologist, 58, 511.
Zeiss, A. M., Lewinsohn, P. M., & Munoz, R. F. (1979). Nonspecific improvement
effects in depression using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of Consulting and Clinical Psychology, 47,
427439. doi:10.1037/0022-006X.47.3.427
246 references
2/8/13 11:14 AM
Index
After-school programs, 162
Agencies, buy in from, 189191
Alcohol-abusing runaway youth,
outcome research for, 46, 57
Alcohol use and abuse. See Substance
use and abuse
Alexander, J. F., 2224, 2935, 3740,
5052, 62, 68, 78, 220, 226
Alliance(s)
of therapist with parents/adolescents,
3234
working, 195196, 215
Alternatives, presentation of, 147148
Androgyny, 120
Anger
reframing of, 108
and stimulus-control interventions,
136
Anger management (case example),
179, 180
Anglo families, outcome research for, 56
Anthony (case example), 167184
Behavior Change Phase, 177182
Engagement Phase, 168171
family demographics, 168
Generalization Phase, 182184
Motivation Phase, 171176
referral information, 168
Relational Assessment Phase,
176177
termination, 184
Aos, S., 45
Appreciation, in Behavior Change
Phase, 140
Appreciation, of therapist efforts, 215
Arbuthnot, J., 41, 42, 53
Arguing, 127
Arrested youth, outcome research for, 43
Assigned tasks, in supervision, 208
Attachment, self-regulation, and
competency (treatment
approach), 226
Attention
acting out for, 154
and maladaptive behavior, 136
Abandonment, and relational connection, 121

Abusive strategies (of parent), 118
Academic impairment, and depression,
231
Acknowledgment
of negative behaviors, in reframing,
101102
of therapists statements, 215
Acting out, 154
Active listening, in communication
training, 148
Adapted model of FFT, 6062
ADHD (attention-deficit/hyperactivity
disorder), 41, 225
Adherence
defined, 203
enhancing, with supervision,
211213
maintenance of, 213214
in outcome research, 59
in real-world settings, 200, 201
and supervision, 202203
Adherence monitoring systems, 5960,
205
Administrators, and success of FFT
implementation, 189191
Adolescence, parenting tasks in
childhood vs., 2223
Adolescents. See also Youth
contracting with, 144145
developmentally-appropriate change
plans for, 133
disruptive behavior disorders in,
219, 222
and FFTCW, 227
major depressive disorder in,
229, 230
psychotherapy for, 19
and relational connection, 120
and relational hierarchy, 124
support from therapists for parents
and, 3234
Aftercare interventions, outcome
research on, 57
247
13190-16_Index.indd 247
2/8/13 11:14 AM
Attention-deficit disorder, 165

Attention-deficit/hyperactivity disorder
(ADHD), 41, 225
Attitude, therapist, 8990
Autism programs, reinforcement strategies
in, 141
Automatic processing, 88
Average competence, 203
Bad behavior, reframing of, 109
Balance of control, 124
Bandura, A., 19, 24
Barnoski, R., 45, 5859
Barton, C., 24, 2930, 34, 38, 39, 52,
220
Beavin, J. H., 101
Beck, A. T., 230
Becker, S. P., 226
Been there, 106
Behavioral rehearsal, 137
Behavioral specificity, of communication,
147
Behavioral strategies, 1920
Behavioral themes, 107108
Behavior change
in Relational Assessment Phase,
117118
transition to, in Behavior Change
Phase, 131132
Behavior Change Phase, 911, 13,
129155, 227, 228, 230, 231
case example, 177182
change plans in, 132135
in FFTG, 222
goal of, 130
and learning theories, 136137
length of, 72
techniques used in, 137155
and therapist skills/behaviors, 132
transitioning into, 112
transition to behavior change and
return to motivation in,
131132
transition to Generalization Phase
from, 158161
and unique family characteristics,
130131
Behavior change strategies, with substance
abuse, 223224
Bem, S. L., 120
Benderix, Y., 43, 54

Benjamin, L. S., 24, 119
Blaming attributions, in therapy, 30
Blended households, session participants
in, 71
Blueprints for Violence Prevention
programs, 6, 18, 52
Boles, S. M., 188
Bonding, within-family, 3334, 228
Booster sessions, 7374
Brain, adolescent, 21
Brainstorming, in problem solving,
149150
Brevity, of communication, 147
Brody, J., 44, 48, 220
Brody, J. L., 44, 45, 47, 49
Bronfenbrenner, U., 24
Buy in, from agencies and funding
sources, 189191
California Institute of Mental Health,
5960
Callousunemotional presentation, 114
Caseloads, 191
Case management, 196
Case planning, 208209
Catalano, R. F., Jr., 65
Causeeffect models, 19
CBT. See Cognitive behavior therapy
Cederblad, M., 43, 54
Center for Substance Abuse Prevention, 5
Center for the Study and Prevention of
Violence, 5
Chambless, D. L., 37, 50
Change, as developmental process, 67
Change-focus techniques
(Motivation Phase), 9299
Change-meaning interventions, 12
Change-meaning techniques
in Engagement Phase, 8485
in Motivation Phase, 99109
Change mechanisms, research on.
See Process research
Change plans
in Behavior Change Phase, 132135
individualized, 130131, 135
Chemers, M. M., 22
Childhood, parenting tasks in adolescence
vs., 2223
Children, and FFTCW, 227
248 index
13190-16_Index.indd 248
2/8/13 11:14 AM
Child welfare settings, FFT in,

227229
Child welfare system, commitment to
FFT from, 190191
Chores, setting expectations about,
140141
Chronic offenders, outcome research
for, 42
Classical conditioning, 136
Climate, program, 189
Clinical momentum, 193
CM. See Contingency management
Coercion framework, 23
Coercion paradigm, 143
Cognitive behavior therapy (CBT),
220, 226, 230
in adapted FFT model, 61
and learning theories, 136137
outcome research on, 5557
Cognitive processes, and acquisition of
behavior, 136
Cognitive processing therapy, 226
Cognitive schemata, of family members,
8889
Coles, J. L., 22
Commitment, agency, 190
Communication, 230
with community stakeholders,
194196
concreteness in, 147
effective, 110
and negativity in families, 29
with referral systems, 7879
Communication skills training,
145149, 223, 230231
in case example, 177179
and change plans, 131
Communication theory, 20
Community agencies
FFT implementation in, 193
Community-based outcome research,
43, 51, 54, 5860
Community links
developing new, in Generalization
Phase, 162
working with, in Generalization
Phase, 161162
Community resources, 159
Community systems
linking FFT with, 70, 71
and success in FFT implementation,
194196
Competence
defined, 203
enhancing, with supervision, 211213
maintenance of, 213214
monitoring of, 205
Competence levels, and supervision,
202203
Complementary behaviors, 21
Compromise, problem solving with, 150
Concreteness, of communication, 147
Conduct disorder, 225
Conduct-disordered youth, reframing
for, 106
Conflict management (case example),
177179
Confusion
about feedback, 215216
from reframing, 106
Congruence, of communication, 147
Connection, relational, 120124
Contact/closeness, 120, 121, 123
Contingency management (CM),
224226
hierarchy for, 153154
Contracting, 144145, 181182
Control, balance of, 124
Controlling behavior, reframing of, 108
Cost analyses, in outcome research, 41,
44, 45, 53, 58
Cultural issues, with negotiation/
contracting strategies, 144
Davidson, K., 225
Decision making skills, 181
Defensive behavior, reframing of, 108
Defensiveness, therapist, 214215
Delinquency (delinquent youth)
non-delinquent vs., 29
outcome research for, 3839, 42, 45
and within-family negativity, 31
Density, of services, 193
Depressed youth
matching with, 67
index
13190-16_Index.indd 249
249
2/8/13 11:14 AM
Depression, FFT for youth and families

experiencing, 229231
Details of content, therapists focus on,
215216
Developmental process(es)
change as, 67
and change plans, 133
Developmental transitions, family
difficulties in, 133
Diagnostic and Statistical Manual of
Mental Disorders (DSMIV), 225
Discouragement, 112
Discovery-oriented quality improvement
interventions, 211
Dispositional attitudes, of parents, 30
Disruptive behavior disorders, 124, 219,
225
Dissemination, adherence and, 201
Dissemination organization for FFT
(FFT LLC), 5860
Distance/autonomy, 120123
Diversity
of referred families, 6869
of therapists, 192
Divertinterrupt technique, 9293
Divorced households, session participants
in, 71
Do something philosophy, 9899
Dropouts. See Premature termination
Drott-Engln, G., 43, 54
Drug use. See Substance use and abuse
DZurilla, T. J., 149
EBTs. See Evidence-based treatments
Eclectic psychodynamic family therapy,
5152
Ecologically-based family therapy,
outcome research for, 57
Ecological systems, 4, 8182
Ecological theory of human development,
2425
Educational systems, linking FFT with, 71
Education level, therapists, 192
Educators, 164
Effective communication, in Motivation
Phase, 110
Effectiveness, intervention, 205206
Ellis, A., 230
Emotion, and relational function,
123124
Empathy, fearless, 9091, 111

Engagement Phase, 812, 7785
assessment during, 8081
and external systems, 7880
and family system, 8183
intervention strategies of, 8385
Enhanced reframing, 102107
Ethnicity, in outcome research, 56
Evidence-based treatments (EBTs),
227, 230
FFT as, 27, 5051
implementation of, 189
for trauma, 226227
Excuses for behavior, reframes as,
105106
Expectations
of agency members, 190
of family members, 81
of parents about adolescents behavior,
140141
Externalizing behaviors
of therapists, 214215
Externalizing disorders, 219220
External systems, and Engagement
Phase, 7880
Extrafamilial systems, 159
Family(-ies)
engagement of, in case example,
169171
and FFTCW, 227
helping, become normal, 163
individualized change plans for,
130131, 135
interaction of, with schizophrenic
youth, 2122
and major depressive disorder,
230231
116118
and trauma, 226227
working with, in Generalization
Phase, 160161
Family activities, positive, 138140
Family-based interventions
reframing in, 101
and treatment for substance use, 222
Family case managers, 162
250 index
13190-16_Index.indd 250
2/8/13 11:14 AM
Family characteristics
and Behavior Change Phase,
130131
and intervention effectiveness, 205
Family context, 4
Family dysfunction, and depression, 231
Family functioning
observations of, 28
Family members, 4
cognitive schemata of, 8889
developmentally-appropriate change
plans for, 133
expectations of, 81
motivation of, 5
of referred clients, 7980
as session participants, 7172
Family negativity, 6
change-focus interventions for,
9294, 9699
in process research, 2932
Family systems, 4, 8183
Family systems theory, 20
Fathers
and gender factors in therapy, 3435
step-, 127
Fear, reframing of, 109
Fearless empathy, 9091, 111
Feedback
confusion about, 215216
in supervision and training, 201202
and therapist defensiveness, 214215
Female one-up hierarchical pattern,
126
FFP (Functional Family Probation), 196
FFT. See Functional Family Therapy
FFTAD (Functional Family Therapy
alcohol and drugs), 220, 223
FFTCM (Functional Family Therapy
contingency management),
224226
FFTCW. See Functional Family
Therapychild welfare settings
FFTDEP (Functional Family Therapy
depressed youth), 220, 230
FFTG (Functional Family Therapy
gang-involved youth), 220
FFTIR (Functional Family Therapy
integrated reentry), 220
FFTTF. See Functional Family Therapy

trauma-focused intervention
Fidelity reviews, 207
Fiedler, F. E., 22
Figley, C. R., 226
First call, engagement during, 8283
Fixing individual problems, 118
Fixsen, D. L., 188, 189
Flexibility, and successful FFT implementation, 191192
Flicker, S. M., 45, 56
Flow, of treatment, 7476
Flynn, P. M., 189
Foster placements, 39, 42
Freitag, M. J., 33, 34
French, M. T., 44
Friedman, A. S., 40, 54
Functional analysis of behavior
(case example), 180181
Functional Family Probation (FFP), 196
Functional Family Therapy (FFT)
adapted model, 6062
defined, 4
efficacy and effectiveness of, 56. See
also Treatment outcomes
as evidence-based treatment, 27,
5051
evolution of, 18
knowledge of, 204
matching in, 6669
parameters of treatment in, 6976
phases of, 714. See also individual
phases
philosophy of, 115116
relational domains of, 2324
as strength-based model, 4
Functional Family Therapyalcohol and
drugs (FFTAD), 220, 223
Functional Family Therapychild welfare
settings (FFTCW), 220, 221,
227229
Functional Family Therapycontingency
management (FFTCM),
224226
Functional Family Therapydepressed
youth (FFTDEP), 220, 230
Functional Family Therapyganginvolved youth (FFTG), 220
Functional Family Therapy in Clinical
Practice (T. Sexton), 62
index
13190-16_Index.indd 251
251
2/8/13 11:14 AM
Functional Family Therapyintegrated

reentry (FFTIR), 220
Functional Family Therapytraumafocused intervention (FFTTF),
220, 221, 226
Functional impairment, and depression,
231
Functions
defined, 119
relational, 119128
Funding sources, buy in from, 189191
Future barriers, anticipation of, 183184
Gang-involved youth, 221222
Gang members, engagement with, 84, 85
Gender (in process research), 3435
Gender stereotyping, 120
Generalization Phase, 911, 14, 157165,
228229
booster sessions in, 7374
communication in, 196
flow of sessions in, 76
goals/tasks of, 158
intervention strategies in, 159162
length of, 72
and termination of therapy, 162165
and therapist characteristics, 158
Generational patterns (of relational
functions), 118
Glasgow, R. E., 188
Goals
attainment of, 116
therapeutic, 6
Goldfried, M. R., 149
Gordon, D. A., 4142, 53
Graves, K., 41, 53
Group supervision, 206207, 210211
Gustafson, K. E., 41, 53
Haley, J., 21, 22, 66
Hall, G. S., 22
Hansson, K., 43, 54
Harper, R. A., 230
Hawkins, J. D., 65
Heidegger, M., 115
Herbert, M., 145
Hierarchy, relational. See Relational
hierarchy
High-competence therapists, 203
High-risk families, FFT and child welfare

interventions for, 190191
High-risk families, timing of sessions
for, 73
Hispanic families, outcome research
for, 56
HIV
and depression, 231
outcome research, 47
Holistic approach, 4
Hollimon, A., 225
Homework, 140
Hk, B., 43, 54
Hopefulness
and Behavior Change Phase, 131
and Motivation Phase, 112
Hops, H., 45, 4749
Identified patients, 20
Ignoring behavior, 142
Impact statements, 148
Incarceration, delinquent youth released
from, 39, 42
Incentives, 224225
Independence, 162163
Individual problems, fixing, 118
Individual therapy, FFT vs., 51
Infrastructure support, and clinical
outcome, 188189
Institutional support groups, 162
Institution support systems, 162
Interactional context, 30
Interpersonal connection, level of, 24
Interpersonal skills, of therapists, 90
Interpersonal style, of therapists, 132
Interpersonal tasks, in Behavior Change
Phase, 151
Interpersonal theories, 2324
Irwin, K., 188
Jackson, D. D., 101
Johansson, P., 43, 54
Jorgensen, J., 49
Judges, 164
Juvenile justice system
assessments in, 80
communication with, 194195
and Functional Family Probation,
196
linking FFT with, 71
252 index
13190-16_Index.indd 252
2/8/13 11:14 AM
Juvenile offenders, outcome research

for, 5354
Juvenile recidivism, 220
Kerig, P. K., 226
Klein, N. C., 40, 50, 52
Knowledge of FFT, 204
Kovacs, M., 230
Labels, 3
Lantz, B. L., 42
Leadership models, 2223
Leadership styles, matching, 6869
Learning theory(-ies), 136137, 158
Leary, T., 24, 119
Leary Circumplex (Leary Circle), 119
Lewis, R. A., 40, 61
Liddle, H. A., 33
Liddle, N., 35
Lieb, R., 45
Listening
active, 148
in Motivation Phase, 110111
Live-in boyfriends, of mothers, 81
Low competence, 203
Mahar, L., 22
Maintenance, of adherence/competence,
213214
Major depressive disorder
in adolescents, 229, 230
families and, 230231
Male one-up hierarchical pattern, 126
Malouf, R. E., 68
Mands, 23
Marijuana, 225, 226
Marital subsystems, 146
Mas, C. H., 30
Maslow, A., 119
Matching, 6669
Matching-to-sample considerations, 134
Mayfield, J., 45
McGreen, P., 41, 53
Mental health systems, linking FFT
with, 71
Midpointing, 120, 121
Mihalic, S., 188
Miller, J. Y., 65
Miller, M., 45
Mirroring, 66
Mixed messages, 120

Model fidelity
and adaptations of FFT, 60
improving, 209210
and knowledge, 204
reviews of, 207
and successful FFT implementation,
193194
supervision of therapists with different
levels of, 210211
and training/supervision, 193194,
200201
Momentum, clinical, 193
Mood disorders, 225
Morris, S. M., 30
Mother(s)
and gender factors in therapy, 3435
live-in boyfriends of, 81
outcome research for, 54
Motivation, 122
and change-meaning techniques, 100
of family members, 5
lack of, 3
relational functions in, 2324
return to, 131132
of therapists, 209210, 212213
Motivation Phase, 912, 87112
change-focus techniques in, 9299
change-meaning techniques in,
99109
goals/tasks of, 8889
indicators of successful outcomes in,
111112
intervention sequence in, 110111
intervention strategies in, 92109
length of, 72
and Relational Assessment Phase,
114115
returning back to, 131132
role of therapist in, 8991
Motives, reframing of, 101107
Multiproblem delinquent youth, outcome
research for, 43
Multisystemic resources, 162
Nagging
reframing of, 108109
unintentional reinforcement of, 143
Need for attention, 117
index
13190-16_Index.indd 253
253
2/8/13 11:14 AM
Needs, 119
Negative behavior, reframing motivation
for, 101107
Negative reinforcement, 142, 143
Negativity
in case example, 172, 175177
therapists reflection of, 104
within-family, 6, 2932
Negotiation strategies, 144145
Neuropsychology, 21
Newberry, A. M., 35
Newell, R. M., 31
New York City, 225
Noble intentions (reframing), 102107
Nonblaming-relational themes, 99102
Nondelinquent youth, delinquent vs.,
29
Nonverbal behaviors, systematically
attending to positive elements
in, 97
Normal, helping challenged families
become, 163164
Observational approach (process
research), 28
Office of Juvenile Justice and Delinquency
Prevention, 5
One-down behavior, 124, 125
One-up behavior, 124, 125
One-up parenting, 66
Operant learning model, 136
Oppositional defiant disorder, 225
Oregon Research Institute, 59
Organizational readiness, 189
Organizational variables, 189196
agency and funding source buy in,
189191
and clinical outcome, 188189
community/stakeholder interface,
194196
process of therapy, 192194
therapist, 192
time and flexibility, 191192
Organizing themes, 62
Outcome monitoring, 205206
Overscreening, of cases, 194
Overwhelming, therapists experience of
feedback as, 215216
Ozechowski, T. J., 44, 47, 48, 49
Pain, reframing of, 109

Parenting classes, 162
Parenting skills, 228
Parenting tasks, in childhood vs.
adolescence, 2223
Parents. See also Mother(s)
dispositional attitudes of, 30
engaging, 8182
expectations about adolescents
behavior, 140
problem behaviors of, 79
117118
and relational hierarchy, 124, 126
and substance use, 222, 223
substance use/abuse by, 165
support from therapists for adolescents
and, 3234
Parent training, 140143
Parsons, B. V., 23, 29, 38, 40, 5052,
62, 78
Participants, FFT session, 7172
Patterson, G. R., 23, 29, 114, 143
Peer influences, 116
Peers
extending skills to, in case example,
182
and relational hierarchy, 126
Penalties, setting, 145
Pennucci, A., 45
Perez, G. A., 32
Performance, therapist, 204205
Peterson, T. R., 44
Phase-based process, training as, 202206
Phipps, P., 45
Piercy, F. P., 40
Planning, for supervision, 206207
Pointing process technique, 9394
Positive elements, attending to, 9698
Positive family activities, 138140
Positive reframing, 3031, 224
Positive reinforcement, 142
Posttraumatic stress disorder (PTSD),
220, 226
Practice exercises (Behavior Change
Phase), 138
Preadolescents, responsecost techniques
for, 145
Premature termination, 29, 3334
Presentation of alternatives, 147148
254 index
13190-16_Index.indd 254
2/8/13 11:14 AM
Prestopnik, J. L., 46, 57

Pretreatment assessments, 8081
Principles, in Behavior Change Phase,
137
Privileges, loss of, 145
Probation counselors, 164
Probation services
Functional Family Probation, 196
outcome research for youths in,
5354, 58
Problem-focused interventions,
relationally- vs., 96
Problem recognition, 149
Problem-solving skills training,
148150, 223, 230
Process research, 2736
family negativity in, 2932
gender in, 3435
observational approach to, 28
therapist support for parents and
adolescents in, 3234
Program climate, 189
Protective processes. See Risk and
protective processes
Proximal outcomes, 6
Psychodynamic theory, 19
Psychotherapy, 19
PTSD (posttraumatic stress disorder),
220, 226
Public health workers, 164165
Punishment, in contingency management, 141143
Quality assurance, with supervision, 211
Quality improvement, supervision for,
211213
Questioning, and listening, 110111
Questions, strength-based, 127
Randomized clinical trials, 51
Rationale, in Behavior Change Phase,
137, 138
Recidivism
in Generalization Phase, 160
juvenile, 220
in outcome research, 3843, 45, 46,
51, 53, 58
and premature termination, 29
and responsiveness, 193
Reciprocal determinism, 24
Reciprocal influences on behavior, 19

Reciprocity cycle, 114
Recognition, of therapists efforts, 215
Referral systems, 7880
Reflection interventions, 3132
Reframes, 101
examples of, 108109
themes vs., 107
Reframing, 101107
interventions involving, 3132
outcome research on, 5253
positive, 3031, 224
and sequencing, 95
for therapists, 215
Regas, S., 41
Regularity, of services, 193
Reid, J. B., 114
Reinforcement
in contingency management, 141143
with responsecost techniques, 145
Reinforcement strategies, 140141
Reinforcers, rewards vs., 141142
Relabeling, 101, 105, 108109
Relapse prevention techniques, 183, 223
Relational assessment, 8081, 113114
Relational Assessment Phase, 913,
113128, 228
assessment in, 119128
and behavior change, 117118
and FFT philosophy, 115116
goals/tasks of, 115
overview of, 113115
relational connection in, 120124
relational hierarchy in, 124126
Relational capital, 88
Relational connection, 6667, 120124
Relational domains (of FFT), 2324
Relational functions, 7, 119128
and behavior change techniques,
154
connection, 120124
hierarchy, 124126
and positive family activities, 140
and resistance to behavior changes,
130131
and responsecost techniques, 145
Relational hierarchy, 124126
as FFT relational domain, 24
matching familys, 6869
index
13190-16_Index.indd 255
255
2/8/13 11:14 AM
Relational impact, 2022

Relationally-focused interventions
problem- vs., 96
Relational patterns, 116
Relational role, of therapist, 89
Relational statements, strength-based, 98
Relational styles, and communication
training, 148
Relational themes, 108
Relationship hierarchy
and contingency management,
153154
and leadership in families, 2223
for schizophrenic youth, 21
Relationship patterns, adapting behavior
change strategies to, 153154
Relationship skills, of therapists, 90
Relaxation training, 135, 154
Rent assistance, 162
Respect, demonstrating, 67, 68
Responsecost techniques, 145
Responsiveness, and recidivism, 193
Review (in case example), 179180
Rewards, reinforcers vs., 141142
Risk and protective factor lists, 114
Risk and protective processes
and ecological theory of human
development, 2425
in outcome research, 38, 40, 43, 44, 48
Robbins, M. S., 3133, 35, 37, 49, 225
Rogers, E. M., 188
Rohde, P., 49
Role-playing, in supervision, 213
Safety, in FFT, 190191
SASB Circumplex system, 119
Scherer, D., 48
Schiavo, R. S., 22, 29
Schizophrenia, 2122
School-based programs, 162
School systems, working relationships
with, 195
Sequencing technique, 9496
Sessions, treatment. See Treatment
sessions
Settings, for FFT, 72
Sex-role stereotyping, 34, 35
Sexton, T., 46, 5859, 62, 201
Shadish, W. R., 40, 54
Siblings
delinquency of, 52
as session participants, 71
Simpson, D. D., 189
Single mothers, matching with, 69
Site-related characteristics
and intervention effectiveness,
205206
reviews of, 207
Skills and skills training, 230231
extending, to peers, 182
family memberintitiated skills, 162
in Generalization Phase, 158
and interventions, 222, 223
parenting skills, 228
relationship skills, 90
therapist skills, 132
Skinner, B. F., 19
Slesnick, N., 44, 46, 57
Social context, family negativity and,
2930
Social engineering, 19
Social learning model, 136
Social learning strategies, 1920
Social media sources, 162
Socialrelational leadership style, 22, 23
Social skills sessions, 230
Social work, 162
Sociopaths, 105106
Source directness (communication
training), 146147
Source responsibility (communication
training), 146
Specificity, communication, 147
Sprenkle, D. H., 40, 41
Stakeholders, and success in FFT
implementation, 194196
Stanton, M. D., 40, 54
Stepfamilies, 71
Stepfathers, 127
Stereotyping, gender, 120
Stimulus-control interventions, 136
Strategies, 116, 162
Strength-based interventions
for therapists, 215
Strength-based models, 4
Strength-based questions, 127
Strength-based relational statements, 98
Stresscoping model, 136
256 index
13190-16_Index.indd 256
2/8/13 11:14 AM
Structural Analysis of Social Behavior

(SASB) Circumplex system, 119
Structuralstrategic therapy, 61
Structuring interventions, 3132
Substance use and abuse
and context, 188
in outcome research, 40, 4449,
5457, 61
by parents, 165
treatment of, with FFTCM, 224226
Substance use disorders
behavior change techniques with,
222223
depression and, 229
in outcome research, 45, 47, 49,
5455, 57, 61
Success factors in FFT implementation,
187197
buy in from agencies and funding
sources, 189191
and context, 188189
Functional Family Probation, 196
interface with community systems/
stakeholders, 194196
therapists, 192
therapy process, 192194
time and flexibility, 191192
Supervision, 199217. See also Training
and adherence/competence, 202203
clinical outcome and quality of, 188
common experiences in, 214217
defined, 202
effectiveness of, 205206
and knowledge of FFT, 204
and model fidelity, 193194, 200201
and performance, 204205
role of working team in, 209214
structure of, 206209
time for, 191
of youth in juvenile justice system,
196
Support, for parents and adolescents,
3234
Support/Monitor Phase, 228, 229
Symmetrical behavior, 124, 125
Systems
commitment of, to FFT, 190
linking with, 7071
Systemsbehavioral versions of FFT, 21
Szapocznik, J., 33
Take a risk philosophy, 9899

Tantrums, 116
Task-oriented leadership style, 22, 23
Teaching interventions, 211, 212
Technical aids
in change plans, 134
Termination of therapy, 162165
case example, 184
criteria for, 76
premature, 29, 3334
Theme hints, 100101
Themes, creating, 107109
Therapist(s), 67
characteristics of, in Motivation
Phase, 8991
motivation of, 209210, 212213
role of, in Generalization Phase,
158
skills/behaviors of, in Behavior
Change Phase, 132
and successful FFT implementation,
192
supervision and performance of,
204205
support from, for parents and
adolescents, 3234
Therapy
as process, 192194
venues for, 72, 82, 192
Time factors
in FFT implementation, 191192
session timing, 73, 193
Training, 199206. See also Skills and
skills training; Supervision
clinical outcome and quality of, 188
communication skills, 145149,
177179, 223, 230231
and knowledge of FFT, 204
and model fidelity, 193194, 200201
parent, 140143
and phase-based process, 202206
problem-solving skills, 148150,
223, 230
relaxation, 135, 154
time factors with, 191
Transportation barriers, 72
Trauma, 226227
Trauma-focused CBT, 226
Treatment fidelity, 188189
index
13190-16_Index.indd 257
257
2/8/13 11:14 AM
Treatment outcomes, 3762

in adapted model of FFT, 6062
community-based, 5860
early, 5153
evidence-based, 5051
independent replications of, 5357
Treatment resistance, 19, 222
Treatment sessions
booster, 7374
flow of, 7476
locations for, 72, 82, 192
number of, 72
participants in, 7172
timing of, 73
Trepper, T. S., 40
Triggers, identification of, 223
Trust, 79
Turner, C. W., 24, 2933, 35, 39, 4449,
52, 5859, 62, 201, 220, 225
12-step facilitation programs, 162
Two-parent families
communication training for, 146
therapist support for parents/
adolescents in, 3233
Unstable family (term), 99
Urge surfing, 223
Urine screening, 225
U.S. Surgeon Generals Report, 6
Venues, for therapy, 72, 82, 192
Vogt, T. M., 188
Vouchers, 224
Waldron, H. B., 30, 35, 37, 39, 44, 45,
4749, 52, 5455, 220
Warburton, J., 34, 39, 52, 220
Washington State, 5859

Washington State Institute for Public
Policy, 58
Watzlawick, P., 101
Webster-Stratton, C., 145
Weissman, A., 230
Whining, 2324, 142
Within-family bonding, 3334, 228
Within-family negativity, 6, 2932
Working alliances
of therapists and community
stakeholders, 195196
of therapists and supervisors, 215
Working relationships
with community stakeholders,
195196
for supervision, 209210
Working teams, 209214
Work issues, parents, 127
Youth. See also Adolescents
delinquent vs. non-delinquent,
29, 30
depression in, 67, 229231
externalizing disorders in, 219220
gang-involved, 221222
internalizing disorders in, 220
outcome research for, 39, 4247, 49,
5358, 61
reframing for conduct-disordered,
106
schizophrenic, 2122
supervision of, in juvenile justice
system, 196
Youthing skills, 134
Zavala, S. K., 44
258 index
13190-16_Index.indd 258
2/8/13 11:14 AM
About the Authors
James F. Alexander, PhD, created the core elements of Functional Family

Therapy (FFT) in 1971 and has been researching and helping others implement the model since then. He provides training and supervision to FFT
therapists across the United States and worldwide. In addition to his work
with FFT, Dr. Alexander has enjoyed being a professor at the University of
Utah for 40 years.
Dr. Alexander has had fellowships with American Psychological Association (APA) Divisions 12 (Society of Clinical Psychology) and 43 (Society
for Family Psychology) and has served as president of Division 43. He has
received several awards for his contributions to family therapy and research
from APA, the American Association for Marriage and Family Therapy, the
American Family Therapy Academy, and the University of Utah. Most notably,
he received the APA Presidential Citation for Lifetime Contributions to Psychology in 2009. He has also been honored for his teaching at the University
of Utah.
Dr. Alexander has served on the editorial board for several familyrelated journals, including as senior consulting editor for The Family Psychologist. He has received training and research grants from the National Institute
259
13190-17_About the Authors_3rdPgs.indd 259
2/8/13 11:08 AM
of Mental Health, the National Institute on Drug Abuse, and the University
of Utah. He has published three books on FFT and more than 80 articles and
chapters and has given hundreds of presentations and webinars nationally
and internationally.
Holly Barrett Waldron, PhD, is a senior scientist at the Oregon Research
Institute (ORI) and director of the ORI Center for Family and Adolescent
Research. She has been involved with Functional Family Therapy (FFT)
clinical development and research for over 30 years, including the early
efforts of the FFT team at the University of Utah and later the development
of the FFT Blueprint for Violence Prevention model for the University of
Colorado Center for Violence Prevention. She began training FFT therapists
in the clinical psychology and licensure for alcohol and drug abuse counseling
programs at the University of New Mexico in 1988.
Dr. Waldron also established a program of research evaluating FFT
through a series of clinical trials funded by the National Institutes of Health. To
date, she has conducted more than a dozen randomized clinical trials and other
investigations examining the efficacy and effectiveness of FFT. Her research
and clinical efforts have focused on the implementation of FFT for adolescent substance use disorders, delinquency, depression, and HIV risk behaviors.
The investigations she and her colleagues at ORI have conducted have led to
innovations in FFT, including specialized behavior change technologies for
substance abuse and depression, evidence-based strategies for integrating motivational incentives into FFT to promote abstinence, and strategies for reducing drug use relapse and recidivism through an FFT aftercare program. She is
currently directing research to evaluate FFT supervision using observational
training methods and evaluating the delivery of FFT to rural families via a webbased video link. As a scientistpractitioner, Dr. Waldron is actively engaged
in FFT dissemination and has extensive experience training and supervising
FFT therapists in community settings. She has developed a Spanish-language
training system for FFT and has trained FFT therapists working with Spanishspeaking families in the United States and in Latin America. Dr. Waldron
is currently disseminating FFT through Leading Implementations in Functional Family Therapy Co. (LIFFT). The primary focus of LIFFT is to expand
the adoption and reach of the FFT model nationally and internationally,
with an emphasis on treating drug abuse and related problems.
Michael S. Robbins, PhD, completed his doctorate in clinical psychology at
the University of Utah and a clinical internship at the University of Miami
School of Medicine. He served as research associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami
School of Medicine for 15 years. He is currently a senior scientist at the
260 about the authors
2/8/13 11:08 AM
Oregon Research Institute and research director for Functional Family Therapy,
LLC. Dr. Robbins has many publications in the area of family therapy for
adolescents with behavior problems. He has extensive experience conducting clinical research on family therapy with drug-using, delinquent adolescents and their families, including innovative process studies that involve the
examination of in-session processes across three empirically validated family
interventions as well as large multisite trials examining the impact of family
therapy in real-world settings. He has directly overseen the training of hundreds of family therapists both nationally and internationally. Dr. Robbins is
a frequent lecturer and consultant and is recognized as a leader in the areas of
process and outcome research in adolescent drug abuse treatment.
Andrea A. Neeb, MS, received her master of science degree from Nova
Southeastern University in 2001 and became a licensed mental health counselor in 2004. Over the past 10 years, she has worked with Functional Family
Therapy (FFT), LLC, as a trainer and consultant. She has been involved in
the dissemination and training of the FFT model to organizations throughout the United States and Europe. Ms. Neebs primary focus of work has
been in the clinical development of therapists in their practice of the FFT
model with diverse client populations and settings.
about the authors
261
2/8/13 11:08 AM
2/8/13 11:08 AM

James F. Alexander, Holly Barrett Waldron, Michael S. Robbins, and Andrea A. Neeb-Functional Family Therapy For Adolescent Behavior Problems-American Psychological Association (AP

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

James F. Alexander, Holly Barrett Waldron, Michael S. Robbins, and Andrea A. Neeb-Functional Family Therapy For Adolescent Behavior Problems-American Psychological Association (AP

Enviado por

Direitos autorais:

Formatos disponíveis

APA Func Family_Title_Activities Teaching Positive Title Page 2/7/13 10:26 PM Page 1

American Psychological Association

Early Influences: The Cultural, Conceptual,

Research on Change Mechanisms................................... 27

Research on FFT Outcomes............................................. 37

II. The FFT Clinical Model..................................................................... 63

Matching and General Parameters of FFT....................... 65

Relational Assessment Phase......................................... 113

Behavior Change Phase................................................. 129

Generalization Phase...................................................... 157

Anthony: A Case Example............................................ 167

III. Administering and Extending FFT................................................. 185

Features of Successful FFT Implementation.................. 187

Training and Supervision............................................... 199

Application of FFT to Distinct Populations.................. 219

justice, child welfare). Irrespective of referral source, youth typically are

was designated one of the 11 Blueprints for Violence Prevention programs

vating family members to change by creating a context that is less negative

Figure 1. Phases of Functional Family Therapy.

Negative perception about or

Risk and protective

Create a motivational context

Maintain and expand

10 functional family therapy for adolescent behavior problems

Blaming attributions decrease;

Specific changes are

availability, telephone outreach, appropriate language and dress, proximal

14 functional family therapy for adolescent behavior problems

The evolution of FFT can be roughly divided into three periods:

Context and relational impact thus often provide considerably more

Our goal in this chapter is to share how researchers have contributed

Process research is explicitly concerned with understanding the clinical

Effects of Negativity in Families

For example, are interactions different when the situation or context is

within-family relationships in theoretically predicted ways during the initial

Subsequent studies also demonstrated that clients appear to prefer that

36 functional family therapy for adolescent behavior problems

Together with clinical observation, basic family interaction research,

38 functional family therapy for adolescent behavior problems

Delinquent youth arrested

Delinquent youth arrested

Study and location

Recidivism: FFT recidivism

research on fft outcomes

Seriously delinquent youth

Status offender delinquent

Delinquent youth referred

Recidivism: A rate of 26%

40 functional family therapy for adolescent behavior problems

Youth reporting regular

Klein, Alexander, and

Study and location

Treatment and comparison

Recidivism: A rate of 20%

research on fft outcomes

Matched assignment, with

Youth with ADHD diagnosis referred to child

Rural, lower SES delinquent youth; juvenile

Regas and Sprenkle

ADHD: FFT and group therapy produced significant

42 functional family therapy for adolescent behavior problems

Delinquent youth released

Study and location