In a similar vein, I’m curious about the marriage. I wonder why this intervention overlooked their relationship. I was concerned, for example, that Ellen seemed so passive and withdrawn, while Edward was so furious at that first meeting. Sexton was skilled at containing and shaping the session, but he risked more than I would have; with residential placement and possible adoption disruption on the line, I’d have worried about the couple’s relationship, too.
Was the function of Sarah’s acting out an indicator of some other issues that didn’t (and shouldn’t) involve her? For example, was her fear of losing her adoptive parents an expression of sensitivity to a different threat—of divorce, for instance? Was Edward’s anger a problem for Ellen, too? Why was Ellen so vigilant about Sarah’s self-harm that the fear about it was “her issue?” Why wasn’t it Edward’s concern, too? Presenting problems are surely relational, as Sexton wisely notes, and defiant adolescents often point the way to other relationship work that needs to be done.
My final musing is about what was really effective in this clearly effective intervention. There’s a robust literature suggesting that technique accounts for about one percent of the variance explaining why clients get better in treatment. Sexton’s adherence to his FFT model is important, of course, but his belief in this approach and the hope he held for this family are possibly more important than the specific tasks he describes.
I wondered about the qualities Sexton possesses that make him a gifted counselor. He appears to view his role as one of teacher, coach, and facilitator, as much as therapist. However, his sensitive attention to process, underlying affect, and mutual desire for closeness and connection suggests that he’s doing psychotherapy—with a family who really believed he could help them. Although he gives lots of credit for his success to the “GPS” provided by the FFT model, I imagine his success is more about his close attention to alliance, his dexterity with interpretation, and his ability to create and hold a suitably resonant frame for this troubled family.
We all follow models when we work with clients. Some therapists’ models are implicit. For me, an explicit and specific model with good evidence that it can work is the core of what allows me to be a creative therapist. In fact, I find that my therapeutic creativity only can exist within the structure of a model. Across disciplines and tasks, researchers are discovering the secret behind creativity is based on having a tested and reliable structure and hours of practice for complex tasks to become automatic enough that we can work in, and between, the structure.
The most recent psychotherapy research echoes these findings—some ways of working are better than others, particularly when it comes to problem adolescents and their families. But, as Martha Straus points out, this work suggests that there’s more to it than a model. In fact, the key ingredient in the success of effective models of practice is following the model with creativity.
This is what FFT provides me: the structure to be creative in a way that lets me go beyond my own limitations and the relational “pull” in the room to provide a pathway for successful change. In this case, it might be easier to see the parents and youth individually, yet the principles of FFT show how separating parents from youth or using a genogram does little to give voice to the parents or the youth, because it may actually promote the negativity and blaming that have the family stuck. Unlike Straus, I don’t worry about Ellen’s quietness or the need to let the parents tell me what they want without their adolescent present. The FFT model is built on the notion of respect. That respect goes so far as to allow people their quietness. By taking a conjoint approach, we hope to bring the family’s relational activities into the room and give everyone a voice, so that we can intervene in a way that’s personal, relevant, and real.
FFT lets me to move beyond my therapeutic habits, values, and potential discomfort with conflict. The model helps me respect clients for who they are and push myself to take advantage of the opportunities in the room and, thus, facilitate changes that have a powerful impact. So, while I appreciate Straus’s complimentary view of my therapeutic skills, I’d suggest that it’s the model that gives me the map to follow. This reliable and tested approach is the structure within which my creativity can exist. Good practice and sound models are like all dialectics— inseparable.
Thomas Sexton, Ph.D., one of the developers of Functional Family Therapy, is a professor in the Department of Counseling Psychology at Indiana University. His books include The Handbook of Family Therapy and Functional Family Therapy in Clinical Practice. Contact: email@example.com.
Martha Straus, Ph.D., a professor in the Department of Clinical Psychology at Antioch University New England and adjunct instructor in psychiatry at Dartmouth Medical School, is the author of No-Talk Therapy for Children and Adolescents and Adolescent Girls in Crisis: Intervention and Hope. Contact: firstname.lastname@example.org.
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