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Case Study - Page 4

The specific agreement negotiated by a family is much less important than helping them follow a process that develops and builds negotiation competence. At this point in the behavior change phase of FFT, I’m not mediating between family members or helping them forge acceptable agreements to solve specific problems, but coaching them in how to competently negotiate their own agreements.

In the three behavior change sessions with this family, focusing on their most salient presenting issue (escalation of anger around Sarah’s return home), they practiced the negotiation and conflict-management strategies I’d taught them. The goal was to help them tailor these skills to multiple situations as they came up. During the sixth session, we focused on the many ways in which the strong emotion generated by their volcanic reactions was likely to pull them back into old patterns. I reframed their discouragement when additional struggles came up—like Sarah’s continued drug use—and helped them generalize what they’d learned.

Seeing the Results of FFT

By now, the practice of negotiating issues together had helped the family internalize a sense of themselves as part of an alliance: Sarah was no longer regarded as a source of their difficulties: her problems were their problems, and vice versa. With this new, expanded sense of themselves as an integrated family unit, a team—along with their generalizable skills at working through problems together—they could become more proactive at addressing other issues in new ways. For example, I initiated a conversation about Sarah’s school and learning difficulties, and the parents, on their own, sought out the resources of the mental health center to seek a psychiatric consultation. The new psychiatrist diagnosed Sarah with an attention deficit problem—definitively ruling out bipolar disorder—and prescribed a medication, which Sarah willingly took. In addition, through the same mental health center, the family identified a specialized learning environment for Sarah with smaller class sizes, where she enrolled. The fact that the family found and made use of these resources on their own represented a milestone for them and indicated that the goals of the generalization phase had been accomplished.

After six months, during a follow-up appointment, I discovered that Sarah had been arrested once for a minor curfew violation. While discouraging, this represented a relatively small problem, given Sarah’s history. In addition, the father and Sarah had experienced a few explosions, but generally, the family was able to reapply the skills they’d learned through FFT to get back on track. What’s more important, the family had successfully managed setbacks by using the conflict-management skills they’d learned during the behavior-change phase of treatment. Sarah was successfully meeting the requirements of the special school program, coming home close to the expected time, and taking her medication as prescribed. Better still, despite ongoing challenges, her parents hadn’t threatened to have her removed from the home: they’d become a united family, fully committed to one another.

CASE COMMENTARY

By Martha Straus

Thomas Sexton presents a model for conducting brief family treatment with a complex case, and demonstrates some deft and inspired strategies for diffusing anger, reframing conflict, and forming working alliances in therapy. By delving beneath displays of aggression and rage toward more vulnerable feelings of fear, abandonment, hurt, and confusion, he creates connections with the different family members, and then provides them with skills for negotiating and managing conflict.

I have three questions about this interesting work. First, I wonder about the decision to begin treatment with the entire family when the situation is so volatile. In my experience, it’s often useful to have a first session with parents to hear about their concerns and expectations for therapy. Without the reluctant and reactive adolescent in the room, I’d opt for a careful genogram, a detailed developmental history, and begin to establish an adult agenda going forward.

Indeed, with adolescents adopted as toddlers, there’s usually a relevant back story that concerns the parents’ marriage, the decision and circumstances surrounding the adoption, and the legacy of early attachment trauma that helps explain—and reframe—the oppositional coping strategies employed by young people like Sarah. Parents benefit from being able to describe freely what they’ve gone through. As in Sexton’s case, these families have often had numerous prior interventions. So wouldn’t it have been useful to clarify how this one would be different, to make manifest the goals of FFT, to give Edward and Ellen a distinct voice?

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