Functional Family Therapy: A New Road Map for Behavioral Change

Sarah’s arrest came as a complete shock to her parents, Edward and Ellen. True, the 15-year-old had experienced difficulties for many years. Since starting high school, she’d begun running with the wrong crowd and started smoking dope. Still, with all the therapy through the years focused on helping her learn to control her anger, Edward and Ellen thought the worst was behind them. They certainly didn’t expect a cop at the door saying that their daughter had been caught riding in a car with a group of teens who’d robbed an electronics store. This was the “last straw” for her parents, who were now considering whether to send her to a residential treatment facility.

When Sarah and her parents came to the first session, they were tense and upset. My first question—“Can you tell me what goes on between the three of you?”—was immediately met with an angry outburst from Sarah’s father, a teacher at the local high school. “I’m done with this! You need to talk with her; we’ve been through enough!” he yelled. Sarah’s mother, said, “Ed, stop it! I am so tired of all this.”

Like many therapists, I want to take action immediately to calm volatile emotions and try to make a difference. But what could I do here?

Finding a Clinical Road Map

Over the years, I’ve found that I’ve needed a solid, research-backed clinical model, which would guide me in sessions and keep me grounded during conflicted family interactions, and be flexible enough to allow me to draw on my intuition, creativity, and sense of the client.

The one I use, based on 30 years of research on the most effective interventions with delinquent and violent juveniles and their families, is Functional Family Therapy (FFT). Like other models, it provides a framework for conceptualizing the case, focusing attention on significant aspects of the client’s dilemma, relational family patterns, and history, and more important, a kind of “clinical GPS” system. It not only shows a way through rough, unmarked territory, but allows you to update decision points and recalibrate the therapy to fit changing circumstances and unexpected developments.

The core notion of FFT is that there’s a beginning, a middle, and an end to the therapeutic change process, which correlates with three distinctly defined phases of treatment: engagement/motivation, behavior change, and generalization. Each has specific goals and requires specific therapeutic skills.

I knew I needed to act quickly to get this family engaged and motivated before the session ran away without me. The clinical GPS that FFT provides told me that the first thing I needed to do to achieve the primary goal of phase 1—engagement and motivation—was to use the event in the room to reduce negativity and blame, and create a family focus. Also, I had to do it in a way that “matched” the family’s style.

The event wasn’t hard to find, so I said: “I’ve been told that all of you were very reluctant to come today, and—as you’ve reiterated—that you’re considering having Sarah live somewhere else. My guess is that what just happened is a reflection of your struggle. I respect and appreciate your honesty, but I need your assistance. Can you help me understand what goes on between the three of you that ends up with this level of discouragement?”

The initial question represented an important core principle of FFT: presenting problems are relational. The goal of the question was to pull them out of an emotional pattern that put the blame on Sarah and shift the focus to the entire family.

Sarah was the first to respond. “What a stupid question! Can’t you see, this is what I have to deal with every day?” she said belligerently. Ellen sighed and turned away again, while Edward said to me, “Now you can see why we can’t take it anymore—she’s so disrespectful.”

“It was a stupid question,” I quickly responded to Sarah. “And it comes from not really knowing how things work in this family. I may never completely understand your feelings or the struggle your parents have in trying to protect you, but what I do know is that the anger you feel gets misunderstood as your unwillingness to try, to listen, and to be respectful. My guess is that what looks to be anger is really fear—fear of losing them.”

Reframing: A Therapeutic Martial Art

This kind of intervention is called a “relational reframing,” a term coined by my colleague Jim Alexander and me. This dynamic form of reframing is really the “judo” of this therapy. As in judo, the therapist “moves toward,” using the powerful emotional momentum already present in the room, to shift the direction of therapy and promote new ways for clients to see themselves and their problems.

By framing the parents’ behavior as the expression of loss, bafflement, and hurt, as well as a heartfelt desire to protect their daughter, I gave myself room to suggest that while their motives and intentions were noble, their reactions to Sarah weren’t always helpful. In other words, I could help them acknowledge their part in the problem, frame it in a way that wouldn’t make them defensive, and start to build a family alliance. This, in turn, would create a safe environment, in which all could talk about difficult issues without reverting to mutual accusations.

Encouraging and Expanding New Behaviors

Behavioral approaches to families like Sarah’s usually focus entirely on communication, problem-solving, negotiating, conflict management, and parenting, but I began by teaching the family how to interrupt escalating interactions that typically occurred when Sarah came home in the evenings. I noted that the family could prevent or interrupt escalations by first negotiating limits to when and how long Sarah would be out on the street, and then learning how to manage conflict when she came home.

Seeing the Results of FFT

After six months, 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, they’d become a united family, fully committed to one another.