Functional family therapy

1. Introduction

Version followed: the FFT LLC five-phase model (Engagement, Motivation, Relational Assessment, Behavior Change, Generalization), as James F. Alexander presented it in 2012 and as FFT LLC / FFT Inc. implementation materials describe it (EPISCenter logic model, revised 2014; FFT LLC slide deck, 2024–25). Where Thomas Sexton's three-phase version (Sexton & Alexander 2000 OJJDP bulletin; Sexton "FFT Associates" materials, Clinical Measurement System 3.0, 2019) differs, the difference is flagged.

Functional Family Therapy (FFT) is a short-term, manualised family programme for young people aged about 11–18 (some sources say 10–18). It targets externalising behaviour, delinquency, violence and substance use, and also internalising problems that show up as behaviour, plus parent–youth conflict. Sessions are delivered mostly in the home. FFT began in 1969 at the University of Utah Family Clinic with underserved, hard-to-engage youth [source: Sexton & Alexander 2000; FFT LLC deck 2024–25; Hess 2020]. It is a licensed programme. Clinicians deliver it under the FFT name only as part of a trained and certified site, with consultant supervision and fidelity monitoring (see 2. Framework, "Certification and fidelity").

How change happens: FFT holds that presenting problems are relational. Problem behaviours are "functional": they influence, and are maintained by, the relationships they sit in [source: Sexton & Alexander 2000; Sexton 2011]. The therapist does not try to change a relationship's underlying function, meaning the degree of closeness or distance and the balance of influence. The developers see these basic motivational patterns as too entrenched to shift in a few sessions. FFT replaces the harmful behaviours that serve those functions with skills that serve the same functions. Motivation must come before skill teaching. First the therapist cuts blame, negativity and hopelessness and builds a family-wide (not youth-only) focus, mainly through reframing and themes. Then the therapist teaches individually matched skills such as parenting, communication, problem solving and conflict management. Finally the family is helped to generalise and keep those skills and to link with community supports [source: Alexander 2012; EPISCenter 2014].

Versions: FFT LLC (Seattle; developer James Alexander) uses five phases and the FFT Clinical Services System (CSS). Sexton's materials merge engagement and motivation into one phase, fold relational assessment into ongoing assessment, and use three phases. They are monitored with the Therapist Adherence Measure (TAM) and the Family Assessment Measures (FAM) [source: Sexton & Alexander 2000; Sexton FFT Associates 2019]. The sources do not explain how these two organisations relate today [uncertain]. Adapted variants exist, such as FFT-Child Welfare and a gang-focused version, but none of their manuals is drawn on [uncertain].

2. Framework

Format and dose [source: FFT LLC deck 2024–25; EPISCenter 2014; Sexton & Alexander 2000; Hess 2020; Foundations guidebook]

• Who attends. Conjoint family sessions with one therapist per family. The "major players" are invited:
  • the members the referrer sees as the problem
  • the members most likely to end treatment
  • the members needed to start change
  • influential extended or support figures, such as a grandparent or close family friend
• Session length and setting. Sessions last 45–60 minutes, mostly in the home; outpatient delivery is possible. Evening and weekend times are offered.
• Number of sessions.
  • About 8–12 sessions for mild cases (2000 bulletin).
  • 12–14 on average, or 12–16, for moderate cases.
  • 26–30 for serious cases.
  • The 2000 bulletin counts up to 30 hours of direct service, including phone calls and community meetings.
• Duration and pacing. 3–5 months; one UK source gives up to 6. One FFT site presentation describes front-loading: three sessions in the first 10 days, then weekly [source: Hess 2020].
• Caseload. 10–12 families per full-time therapist; at least 5 for part-time staff.
• When to start. Start close to the event that triggered the referral, with no gap after the problem is identified.

Referral fit [source: FFT LLC deck 2024–25]

• Include:
  • a youth aged 11–18 (or a young adult) who lives in the community or is about to return to it
  • a family that is available, with some shared history, a sense of a shared future and some co-habitation
• Exclude:
  • a primary referral aged 9 or under
  • no family system
  • a scheduled removal from home (remand, placement, foster care)
  • a need for sexual-offender treatment
  • a primary need that is acute psychiatric, such as active suicidality, homicidality or psychosis
• Lethality first. Deal with lethal or urgent concerns first, such as a child-abuse investigation or substance toxicity.
• Other services. Check whether services running at the same time would interfere with the model.

Phases (FFT LLC five-phase map)

The sources differ on where assessment sits. Alexander lists "relational then behavioral assessment" as a phase. One FFT site presentation places the relational assessment grid inside Engagement & Motivation [source: Hess 2020]. Sexton treats assessment as ongoing and spread across all phases [source: Sexton & Alexander 2000]. In practice the therapist assesses relational functions from the first contact. Formal change planning against those functions happens before skill training starts [synthesis].

Criteria for moving between phases. None of the sources states formal criteria [uncertain].

• What the sources do say:
  • Behaviour-change techniques are applied only after engagement and motivation are in place [source: Alexander 2012].
  • In Sexton's system, family measures are completed in the session before each phase change [source: Sexton FFT Associates 2019].
  • How the parent–youth alliance changes across sessions 1–2 predicts completion versus dropout (Freidag, Alexander & Turner 2008, cited in Alexander 2012).
• Practical markers [synthesis]:
  • Motivation → behaviour change:
    • blaming exchanges in session are clearly fewer
    • every major player attends and has a working alliance with you
    • members describe the problem as a family pattern, not as one person's fault
    • members express some hope
  • Relational assessment → behaviour change: you can state, for each key dyad, the relatedness and hierarchy pattern and the problem sequence, and say which skill will serve that function.
  • Behaviour change → generalization: the family uses the target skills at home with less coaching, and the referral behaviour has fallen.
  • Ending: the family has handled a setback or a new problem with its own skills, and is reaching resources without you.

Certification and fidelity [source: FFT LLC deck 2024–25; Foundations guidebook; Sexton FFT Associates 2019; Sexton & Alexander 2000]

• Site-based implementation. FFT LLC delivers it in three phases:
  • Phase 1, clinical training:
    • kickoff and implementation training
    • an initial 2-day in-person training, a second 2-day virtual training, and three 2-day follow-up trainings
    • weekly Zoom consultation with an FFT consultant, plus peer consultation
    • an externship of three 3-day off-site events
    • use of the CSS
  • Phase 2, supervisor training (the site's own case-carrying supervisor, trained in year 2): two 2-day virtual trainings, consultation every two weeks, an annual site visit.
  • Phase 3, ongoing adherence: monthly supervisor consultation and an annual site visit.
• Team and staff. A team of 3–8 clinicians, usually master's-level (some bachelor's-level exceptions), with 2 hours a week of case consultation.
• Fidelity tools.
  • FFT LLC CSS: a weekly supervision checklist with fidelity and adherence ratings, global therapist ratings every four months, and a site status card.
  • Sexton's system: the TAM (per-session adherence, global and phase-specific), the Supervisor Adherence Measure, and an adherence summary every 6 months. Certification there is competency-based and renewed every 2 years.
• Licensing. A UK clearinghouse lists "no licensing requirement" while naming FFT LLC as the programme owner. The sources do not say whether an individual clinician outside a certified site may use the FFT name [uncertain]. Contact the purveyor before advertising FFT.

3. Guiding principles

[source for each line in brackets]

• Presenting problems are relational. Assess and intervene on interaction patterns, not on the identified youth alone. From session 1, ask about what goes on between people [Sexton 2011, 2015; Alexander 2012].
• Behaviour is functional. Every problem behaviour does something in a relationship, such as creating distance, closeness or influence. Ask what it accomplishes, not just how to stop it [Sexton & Alexander 2000; Alexander 2012].
• Do not judge or try to change the function. Accept a family's level of closeness or distance and its hierarchy on its own terms. Change the behaviours that serve the function, not the function [Alexander 2012].
• Motivation before behaviour change. Do not teach skills to a blaming, hopeless family. Earn motivation first [Alexander 2012; FFT LLC deck].
• Reduce blame, keep responsibility. Reframes lower blame and defensiveness. They never excuse the behaviour or remove accountability [Alexander 2012].
• Balanced alliance. Ally with every family member, not just the most responsive one. Watch for drifting toward whoever agrees with you [Alexander 2012; Hess 2020].
• Respect each member on their own terms. Be non-judgemental and strength-based. Everyone should leave feeling heard and treated with dignity [Sexton & Alexander 2000; Hess 2020].
• Start from strengths and hope. Build the belief that change is possible, even modest change, as a platform for the family to become self-sufficient [Sexton & Alexander 2000].
• Obtainable, family-specific change. The goal is what this family can reach with its resources, values and context, not an idealised "healthy family" [Hess 2020; Sexton FFT Associates 2019].
• Matching at every level. Fit the intervention to the therapist's style, to each member, relationship and family, and to the culture, agency and systems involved. Matching is also the remedy for drift [Alexander 2012; EPISCenter 2014].
• Structured but flexible. Follow the phase map ("Phase Task Analysis"; Sexton's "clinical GPS") for goals and sequence. Improvise how you reach each goal moment to moment [Sexton & Alexander 2000; Sexton 2011].
• Alternate relational and structuring skills. Use relational skills (warmth, validation, reframing) mainly to build motivation. Use structuring skills (directing, modelling, training) mainly for behaviour change [FFT LLC deck; Sexton & Alexander 2000].
• Relational, not individual, focus in sessions 1–2. Completers' therapists kept a relational focus early [Alexander 2012, citing Jensen & Alexander].
• Themes are hypotheses, not interpretations. Offer them tentatively and revise them by how the family responds [Alexander 2012; Hess 2020].
• Fidelity means adherence plus competence. Know which changes are reversible accommodations, such as a different language, and which are adaptations of phases or sequence. Name and track your drift [Alexander 2012].
• Measurement and accountability. Track process and outcome, and use the feedback in supervision and case decisions [Sexton & Alexander 2000; Sexton FFT Associates 2019].
• Multisystemic and ecological. The family is the main target. School, justice and community are part of the work, especially in generalization [Sexton & Alexander 2000; FFT LLC deck].
• Timing and safety. Start close to the referral event, handle lethality first, and check that other services do not interfere [FFT LLC deck].
• Trauma-informed, family voice, developmentally specific. These principles are listed in Sexton's materials. Adjust intensity to risk and stage of development [Sexton FFT Associates 2019].

4. Intervention inventory

The inventory is grouped by phase. Technique names come from the sources cited. Steps are paraphrased and partly synthesised. FFT LLC's full training manual is not drawn on; Alexander (2012) notes it is available on request. Where a step goes beyond what the sources describe, it is marked [synthesis]. All example therapist language is illustrative.

Phase 1: Engagement

4.1 High availability and outreach

• Purpose: make the programme feel responsive and credible before the family has decided to take part, which reduces early dropout. Use it from referral through the first sessions [source: Alexander 2012; Sexton & Alexander 2000; EPISCenter 2014].
• Steps:
  1. Contact the family quickly after referral, close to the event that triggered it [source: FFT LLC deck].
  2. Phone as many family members as possible, not just the referred youth or the most cooperative parent [source: Alexander 2012].
  3. Offer sessions at home, and in the evening or at weekends [source: Hess 2020].
  4. Front-load: schedule as often as needed early on. One site uses three sessions in the first 10 days [source: Alexander 2012; Hess 2020].
  5. Keep making phone contact between the early sessions. One programme that did this retained 80% of the families referred [source: Sexton & Alexander 2000].
  6. Name and solve practical barriers, such as transport, confusion about the programme and reluctance [source: EPISCenter 2014].
• Example language (illustrative):
  • "I'd like to meet with the whole family, at your place if that's easier. What evening works?"
  • "I'm calling each of you, because how this goes depends on everyone's view, not just one person's."
• Watch for:
  • settling for whoever is willing to come [source: Alexander 2012]
  • long gaps before the first session
  • Working: the first session happens with the major players present, and members return calls.

4.2 Identifying and convening the major players

• Purpose: make sure the people who maintain the problem, or who could end treatment, are in the room [source: Hess 2020].
• Steps:
  1. From the referral and the first calls, list:
     • who the referrer sees as the problem
     • who is likely to stop treatment, such as a sceptical parent
     • who is needed to start change
     • influential extended or support figures (for example a grandparent, a parent's partner or a close friend)
  2. Invite each one personally.
  3. If someone refuses, note their position and keep reaching out. Treat their absence as relational information [synthesis].
• Example language (illustrative): "Your grandmother seems to have a lot of say in this house. Would she be willing to join us?"
• Watch for: a family who presents only the youth and one parent when another adult clearly holds power. Working: the decision-makers attend.

4.3 Matching to family values and culture

• Purpose: build credibility by fitting the therapist's style, language and framing to the family's values, culture and context [source: EPISCenter 2014; Alexander 2012].
• Steps:
  1. Learn the family's language, whether religious or community values matter to them, and what they expect of helpers.
  2. Adjust pace, formality and vocabulary.
  3. Separate accommodations, such as delivering in the family's language, from changes to phases or sequence. Accommodations are fine; changes to phases or sequence are adaptations and should be discussed in consultation [source: Alexander 2012].
• Example language (illustrative): "Help me understand how things are usually handled in your family when a child breaks a rule."
• Watch for: imposing a "healthy family" template that conflicts with the family's values [source: Hess 2020].

Phase 2: Motivation

4.4 Balanced alliance building

• Purpose: every major member feels the therapist understands and supports them. This is the base for hope and for reducing blame. Early change in the parent–youth alliance predicts completion [source: Alexander 2012; Sexton & Alexander 2000].
• Steps:
  1. In each early session, make sure each person has a turn and is validated.
  2. Validate each member's emotional experience without endorsing their blame of others. Validation and positive interpretation are listed core skills [source: Sexton & Alexander 2000].
  3. Keep checking whose side you seem to be on. Rebalance by turning to the member you have spoken to least [synthesis].
  4. Keep the focus on the relationship, not on the identified youth [source: Alexander 2012].
• Example language (illustrative): "Mum, you've been carrying a lot of worry. And Jay, I get the sense nobody's really asked what this has been like for you."
• Watch for:
  • drift toward the most responsive member [source: Alexander 2012]
  • a parent seeing the therapist as "soft" on the youth, or the youth seeing the therapist as the parents' agent
  • Working: each member engages with you, and the members begin to address each other with less hostility.

4.5 Relabeling

• Purpose: give a negative behaviour or trait a more benign label, as a first step toward reframing. In Alexander's list, relabeling sits alongside reframing and themes as a separate, simpler skill [source: Alexander 2012].
• Steps:
  1. Pick a behaviour a member describes in blaming terms.
  2. Offer a different, less blaming word for it, for example "stubborn" becomes "determined" and "nagging" becomes "keeping close tabs" [source: Alexander 2012 for the technique; examples are synthesis].
  3. Move on to a reframe that adds a motive (4.6). Relabeling on its own should not be passed off as reframing [source: Alexander 2012].
• Example language (illustrative): "What you call 'mouthing off' sounds like she's really determined to be heard."
• Watch for: relabels that sound glib or deny the hurt. Acknowledge the negative first.

4.6 Reframing

• Purpose: the central motivation technique. It reduces blame and negativity, builds hope and shifts the family from "one bad person" to a shared pattern. It is used constantly in the motivation phase, and repeatedly rather than as a one-off [source: Alexander 2012; Sexton 2011; Hess 2020; EPISCenter 2014].
• Steps:
  1. Acknowledge the negative. Name the behaviour and the pain it causes, so the member doesn't feel dismissed. Alexander stresses doing this before proposing a benign motive [source: Alexander 2012].
  2. Offer a benign, even noble, but possibly misguided intent behind the behaviour, for example protecting someone, fearing loss or wanting to be taken seriously [source: Hess 2020; Alexander 2012].
  3. Make it relational. Link the motive to the relationship. Sexton recasts a teen's defiance as pain and a parent's anger as fear of losing the child [source: Sexton 2011, 2015].
  4. Move with the emotion, not against it. Sexton describes this as "judo": use the energy of the anger and redirect it toward the hurt underneath it [source: Sexton 2011].
  5. Check the response. If members affirm it, build on it. If they reject it, refine it, or apologise for misunderstanding and move on [source: Hess 2020].
  6. Reframe painful history too, so members are not defined only by past acts [source: Hess 2020].
  7. Keep responsibility. The reframe explains the behaviour. It does not excuse it or remove the need to change [source: Alexander 2012].
• Example language (illustrative):
  • "When you shout at him the minute he walks in at 2 a.m., I hear how scared you've been, not just how angry. Is that close?"
  • "Staying out that late does a lot of damage at home. I also wonder if it's your way of trying to get some say over your own life."
• Watch for:
  • Working: less blaming talk, softer body language, members adding to the reframe, a parent admitting their own part without becoming defensive [source: Sexton 2015].
  • Not working: the member argues, laughs it off or feels you've taken sides. Refine or drop it.
  • Never reframe abuse or violence as noble. See section 5 [synthesis].

4.7 Reattribution and positive interpretation

• Purpose: change the explanations members give for each other's behaviour, from bad character to understandable motives or circumstances. Reattribution and positive interpretation are listed core skills of the early phase [source: Sexton & Alexander 2000]. The sources give no separate procedure, so the steps below are [synthesis].
• Steps [synthesis]:
  1. Notice a fixed, negative explanation ("he does it to spite me").
  2. Ask what else might explain it, or suggest an alternative yourself.
  3. Reinforce any shift a member makes toward a less blaming explanation.
• Example language (illustrative): "You've decided he does it to hurt you. I wonder if he even knows how it lands for you."
• Watch for: fixed attributions softening into "maybe" statements.

4.8 Themes: theme hints, positive themes, behaviour-sequence themes and relational themes

• Purpose: link many reframes into one storyline that gives the family a shared, non-blaming account of what they are caught in. Themes are broader and easier to build than single reframes [source: Alexander 2012; Sexton & Alexander 2000].
• Types (Alexander 2012):
  • Theme hints: brief, early suggestions of a possible theme.
  • Positive themes: emphasising, for example, caring or loyalty beneath the conflict [source: Sexton & Alexander 2000].
  • Behaviour-sequence theme: link a specific sequence within the family and reframe its parts to show non-malicious intent.
  • Relational theme: propose misguided but benign, even noble, or accidental intentions behind long-term patterns. It uses relational markers rather than behavioural ones, and can use coincidences.
• Steps:
  1. Collect reframes across members and look for a common thread, such as fear of loss or fierce independence [source: Sexton 2011].
  2. Offer it tentatively as a hypothesis [source: Alexander 2012].
  3. Fit it to every major member, so no one is the villain.
  4. Revise it as the family responds, and come back to it across sessions.
• Example language (illustrative): "It sounds like in this family, people fight hardest when they're most afraid of losing each other. Mum by holding on, Jay by pushing away. Does that fit?"
• Watch for: a theme that blames one member or uses therapy jargon. Working: members start using the theme themselves.

4.9 Sequencing and the "pointing process"

• Purpose: make the interaction pattern visible, step by step, so the family sees the problem as a sequence they all take part in [source: Alexander 2012; Hess 2020; Sexton & Alexander 2000].
• Steps:
  1. Pick a recent incident, or one that happens in the room.
  2. Trace it step by step: "what happened just before... then what did you do... then?"
  3. Point out the specific steps and the links between people's moves [source: Hess 2020].
  4. Pay selective attention to the positive parts of the pattern and of the family's reports [source: Alexander 2012].
  5. Point to the relational link, for example "each time X, Y follows" [source: Alexander 2012].
• Example language (illustrative): "Let's slow that down. Dad, you asked where she'd been. Then she rolled her eyes. Then what happened inside you?"
• Watch for: turning sequencing into gathering evidence against one member. Keep it descriptive.

4.10 Interrupt and divert

• Purpose: stop escalating, highly negative or blaming exchanges in session, which would otherwise confirm hopelessness and raise the risk of dropout [source: Alexander 2012; Hess 2020].
• Steps:
  1. Step in early, as escalation starts.
  2. Interrupt respectfully, for example by raising a hand or using the person's name.
  3. Redirect, for example to one member, to a reframe or to the feeling underneath [source: Alexander 2012].
  4. Sexton's practice: name the tension in the room, then focus on one member [source: Sexton 2011].
• Example language: Sexton named the room's tension as a sign there was "more going on" [source: Sexton 2011]. Illustrative: "Let me stop you both for a second. I don't want this to become another one of those fights you've told me about. Mum, what's the worry underneath?"
• Watch for: being pulled into the family's reactivity yourself [source: Sexton 2011]. Working: exchanges calm down sooner.

4.11 Using the event in the room, and the relational question

• Purpose: use live conflict to show the family its pattern and shift from blame to a family focus [source: Sexton 2011, 2015].
• Steps:
  1. Let an in-session interaction run just long enough to show the pattern.
  2. Ask a relational question about what happens between members, not about one person's behaviour. Sexton asked the family to help him understand what goes on between the three of them [source: Sexton 2015].
  3. Reframe what was just seen (4.6).
• Example language: "Can you help me understand what goes on between the three of you?" [Sexton 2015, verbatim].
• Watch for: letting a harmful exchange run on. Use 4.10.

4.12 Building a family-focused problem definition

• Purpose: replace "the problem is the youth" with a shared definition that involves everyone. This is a stated goal of the early phase [source: Sexton FFT Associates 2019; Sexton & Alexander 2000].
• Steps:
  1. After the reframes and themes, summarise the problem as a pattern between members.
  2. Ask each member whether it fits, and adjust it until all can agree.
  3. Use it as the reference point for the change plan.
• Example language (illustrative): "So the problem we're working on is how fights about curfew spiral, and how everyone ends up feeling unheard."
• Watch for: a member who still insists the problem is one person. Keep reframing and don't push for agreement too soon.

4.13 "Doing something" (taking a risk)

• Purpose: this appears in Alexander's (2012) list of engagement and motivation techniques as "doing something" or taking a risk. The source gives no procedure [uncertain]. A plausible reading is that the therapist makes a bold relational move, such as a direct, unexpected reframe, when safer moves are failing [synthesis]. Do not treat this as a defined FFT technique without the manual.

Phase 3: Relational assessment

4.14 Assessing relatedness (connection ↔ autonomy)

• Purpose: identify, for each key relationship (dyad), whether the problem behaviour serves closeness/contact or distance/autonomy. This guides which skills will fit [source: Alexander 2012; Foundations guidebook; Hess 2020].
• Steps:
  1. For each important dyad, such as mother–son or father–son, look at what each member's behaviour produces in the relationship. Ask whether it brings them together (contact, closeness, at the extreme enmeshment) or creates distance (separation, autonomy) [source: Alexander 2012].
  2. Read the problem behaviour as a relational pattern, not an isolated act. Alexander's examples:
     • adolescent substance use as "pseudo-individuation"
     • running away as a distancing pattern [source: Alexander 2012]
  3. Place each member–member relationship on an autonomy–connectedness grid. One site lists the positions as parent up, parent down, symmetrical and midpointing [source: Hess 2020].
  4. The sources do not define "midpointing". It is usually understood as a mix of both connection and autonomy, but that reading is [uncertain]; check the FFT manual.
  5. Note that the same behaviour can serve different functions for different members [synthesis consistent with dyad-level assessment].
• Example language (illustrative): "When Jay disappears for the weekend, what happens between the two of you afterwards? More contact, or less?"
• Watch for:
  • judging a function as unhealthy. FFT seeks to understand it on the family's terms [source: Alexander 2012].
  • confusing your hopes with what is actually happening [source: Alexander 2012].

4.15 Assessing hierarchy

• Purpose: understand each member's relative influence, from power, position and resources. Patterns range from one-up/one-down to symmetrical [source: Alexander 2012].
• Steps:
  1. Observe who sets the agenda, who gives in and who has the final say on rules.
  2. Classify each dyad as parent one-up, parent one-down or symmetrical [source: Alexander 2012; Hess 2020].
  3. Use the pattern to shape the behaviour-change plan, for example who holds which part of a contract [synthesis].
• Example language (illustrative): "When you two disagree about rules, how does it usually get settled?"
• Watch for: imposing a "parents must be on top" norm before you understand the family's pattern [source: Alexander 2012 on non-judgement].

4.16 Multidomain and behavioural-sequence assessment

• Purpose: an ongoing, multi-method picture of what the behaviour does and of risk and protective factors [source: Sexton & Alexander 2000].
• Steps:
  1. Assess the adolescent: development, psychological conditions.
  2. Assess the family's daily life: parenting, support, provision.
  3. Assess context: risk and protective factors, available resources [source: Sexton & Alexander 2000].
  4. Assess thinking (attributions, coping), interaction (reciprocity, parenting, behaviour sequences) and emotion (blaming, negativity) [source: Sexton & Alexander 2000].
  5. Focus on how the family functions rather than on reaching a diagnosis.
  6. Use the programme's own tools: the Functional Family Assessment Protocol and the CSS (FFT LLC), or the FAM and stability measures (Sexton system). Do not reproduce their items; they are licensed instruments [source: Sexton & Alexander 2000; Sexton FFT Associates 2019].
• Watch for: turning assessment into a separate interview phase that loses momentum. Assessment runs alongside intervention.

4.17 Building a change plan that fits relational functions

• Purpose: turn the assessment into an individualised plan whose skills serve each relationship's existing function [source: Alexander 2012; Hess 2020; Sexton & Alexander 2000].
• Steps:
  1. For each target behaviour, write down the function it serves (for example, distance from Dad, or contact with Mum).
  2. Choose a replacement behaviour or skill that gives the same function in a less harmful way [source: Alexander 2012; Foundations guidebook].
  3. Keep it developmentally appropriate, specific to the family and achievable [source: Hess 2020].
  4. Match it to the theme already built in the motivation phase [synthesis].
• Example [synthesis]: a youth whose staying out serves distance gets a negotiated, legitimate autonomy, such as agreed out-time with check-ins, rather than a plan that forces closeness. A parent whose nagging keeps contact gets a scheduled, positive contact routine.
• Watch for: plans that would require the family to change its basic closeness or hierarchy. That is the kind of plan Alexander warns will fail.

Phase 4: Behavior change

4.18 Standard skill-training sequence

• Purpose: the delivery routine for every skill in this phase [source: Hess 2020; Alexander 2012].
• Steps:
  1. Give the rationale, linked to the family theme.
  2. Present the task.
  3. Model it. The therapist demonstrates, possibly with technical aids such as written prompts [source: Alexander 2012].
  4. Have members rehearse it in session, either planned or using an incident that comes up live [source: Alexander 2012].
  5. Give specific feedback and coach.
  6. Set homework (4.26).
  7. Review the homework next session.
• Example language (illustrative): "You both want fewer blow-ups at the door. Let's try a way of talking about curfew that gives each of you a say. I'll show you first, then you try it."
• Watch for: lecturing without rehearsal; skills taught before blame has dropped (go back to motivation).

4.19 Communication training

• Purpose: replace blaming, escalating talk with supportive communication that serves the family's functions [source: EPISCenter 2014; Hess 2020; Sexton & Alexander 2000].
• Steps [synthesis for detail]:
  1. Choose one or two target behaviours, such as brief statements, "I" statements, listening without interrupting, or asking before advising.
  2. Model, rehearse and coach them on a low-heat topic first.
  3. Then move to the real conflict topic.
• Example language (illustrative): "Try saying what you need in one sentence, starting with 'I'. Jay, your job is just to say back what you heard."
• Watch for: skills used mechanically, or used as weapons ("you're not using I-statements").

4.20 Problem solving

• Purpose: a shared method for recurring problems [source: EPISCenter 2014; Alexander 2012; Hess 2020].
• Steps [synthesis; standard behavioural problem-solving]:
  1. Define the problem in specific, non-blaming terms.
  2. Generate options without judging them.
  3. Weigh the options.
  4. Pick one and plan who does what and when.
  5. Try it, then review it.
• Example language (illustrative): "Let's list every idea for the school-morning problem, even silly ones, before we judge any."
• Watch for: one member dominating the choice. Balance by hierarchy pattern and function.

4.21 Negotiation, contracting, reinforcement and monitoring

• Purpose: produce specific, agreed rules and reciprocal agreements, such as a plan for coming home. Track them [source: Hess 2020; Sexton 2011, 2015].
• Steps:
  1. Coach the family's negotiation process. Do not broker the agreement yourself; Sexton coached the process rather than mediating the content [source: Sexton 2011].
  2. Get specific: who, what, when, the consequence and the reward.
  3. Write the agreement down if that helps [synthesis].
  4. Agree how it will be monitored, and how compliance will be reinforced [source: Hess 2020].
  5. Review and renegotiate in later sessions.
• Example language (illustrative): "You two work out the weekend times. I'll just keep you on track. What's the first offer?"
• Watch for: contracts the youth agrees to under pressure. Check that the terms serve the youth's relational function, such as autonomy.

4.22 Parenting skills ("parenting and youthing") and positive compliance

• Purpose: improve parents' family management and the youth's matching skills ("youthing" in Alexander's term). Build positive parenting and compliance [source: Alexander 2012; Sexton & Alexander 2000; EPISCenter 2014].
• Steps [synthesis for detail]:
  1. Pick specific parenting targets tied to the problem, such as monitoring, clear requests, consistent consequences or praise for compliance.
  2. Give the youth matching targets, such as checking in, asking rather than taking, or accepting a no.
  3. Model and rehearse both sides in session.
  4. Adapt for younger siblings and for developmental level.
• Example language (illustrative): "When she does text you where she is, what could you do so she's more likely to do it again?"
• Watch for: parent training delivered as advice to the parent alone. In FFT it remains relational.

4.23 Conflict management and interrupting escalation

• Purpose: give the family its own way to stop escalation. Sexton taught a family to interrupt its evening escalation before tackling broader skills [source: Sexton 2015; Alexander 2012; Sexton & Alexander 2000].
• Steps:
  1. Map the escalation sequence (4.9).
  2. Agree an early cue and a specific interruption, such as a time-out with a set time to come back [synthesis for the specific form].
  3. Rehearse it in session.
  4. Plan when to return to the issue later.
  5. Practise managing the next conflict at the hot point, such as homecoming [source: Sexton 2015].
• Example language (illustrative): "What's the first sign it's about to blow? Who'll call the pause, and when will you come back to it?"
• Watch for: time-outs used for avoidance or as punishment.

4.24 Individual skills for family members

• Purpose: build individual skills that support the relational plan [source: Hess 2020; EPISCenter 2014; Alexander 2012].
• Skills listed:
  • anger management
  • assertiveness
  • decision making
  • peer-refusal skills [Alexander 2012 lists refusal skills]
  • effective use of free time
  • emotional regulation and coping
• Steps [synthesis]: teach them with the 4.18 sequence, ideally in front of other family members, so the skill sits in the relationship.
• Watch for: sessions drifting into individual therapy that loses the relational focus.

4.25 Problem-specific modules

• Purpose: one FFT site presentation lists modules for specific referral problems [source: Hess 2020; not confirmed in an FFT LLC primary source, so treat their status as [uncertain]]:
  • Substance use: functional analysis of use, coping with urges and cravings, urge surfing, decision making.
  • Anxiety and depression: CBT methods, challenging provocative thoughts, managing low mood.
  • Truancy and trauma: listed without detail.
  • Alexander says change techniques come from many literatures, including cognitive, behavioural, emotional, relational and physiological ones, as long as they fit relational functions [source: Alexander 2012].
• Steps: use the standard evidence-based procedure for each problem, delivered through the 4.18 sequence and matched to function [synthesis].
• Watch for: importing a whole separate protocol in a way that becomes an adaptation of the model. Discuss in consultation [source: Alexander 2012].

4.26 Homework

• Purpose: move skills into daily life [source: Alexander 2012; EPISCenter 2014; Hess 2020].
• Steps:
  1. Make tasks specific, clearly understood, achievable, and with a high expectation of success [source: Alexander 2012].
  2. Agree who does what, and when.
  3. Troubleshoot obstacles before the family leaves [synthesis].
  4. Review the task first thing next session.
  5. Treat non-completion as information, not failure (section 5).
• Example language (illustrative): "This week, just one thing: when Dad asks where you're going, give the street and the time, and Dad says thanks. That's all."
• Watch for: tasks too big for the family's current motivation.

4.27 Psychoeducation

• Purpose: give information that supports the change plan, such as adolescent development or the effects of substances [source: EPISCenter 2014].
• Steps [synthesis]: keep it brief, tied to the theme and non-blaming. Check understanding.
• Watch for: psychoeducation that implicitly blames one member.

Phase 5: Generalization

4.28 Relapse prevention planning

• Purpose: prepare the family to expect setbacks and handle them themselves [source: EPISCenter 2014; Sexton & Alexander 2000; Sexton 2011].
• Steps:
  1. Help the family predict likely setbacks, such as the next school exclusion or a return to old peers.
  2. Reframe setbacks before they happen as expected, not as proof that therapy failed [source: Sexton 2011].
  3. Agree which learned skill the family will use, and who will start it [synthesis].
  4. Rehearse one scenario in session.
• Example language (illustrative): "There'll be a night when things go back to the old way. When it happens, what will tell you it's starting, and what will you do?"
• Watch for: Working: the family deals with a real setback using its skills. In Sexton's case, the family handled a minor setback on its own at six-month follow-up [source: Sexton 2011].

4.29 Generalising skills to new problems and settings

• Purpose: carry the change into other relationships, problems and settings [source: Sexton & Alexander 2000; Hess 2020; Sexton FFT Associates 2019].
• Steps:
  1. Pick a new or related problem, such as a sibling conflict or homework battles.
  2. Ask the family to apply the skills it already has, with less coaching from you.
  3. Reduce your direction step by step.
• Example language (illustrative): "You've sorted out curfew. How would you use the same approach for the phone rules?"

4.30 Linking to community resources and family case management

• Purpose: connect the family to natural supports (extended family, faith, community) and formal supports, and improve its relationships with school and the justice system [source: Alexander 2012; Sexton & Alexander 2000; EPISCenter 2014].
• Steps:
  1. Identify the resources the family needs.
  2. Act as the family's case manager. If necessary, deal directly with school, justice or community systems until the family can do this itself [source: Sexton & Alexander 2000].
  3. Coordinate with the other agencies involved, for example through collaborative team meetings [source: Sexton FFT Associates 2019].
  4. Shift contact with these systems over to the family [synthesis].
• Example language (illustrative): "Next time I'd like you to make the call to the school and I'll sit beside you. After that, it's yours."
• Watch for: the family coming to depend on you. Working: the family seeks out resources by itself [source: Sexton 2011].

4.31 Ending and referral on

• Purpose: end once gains are stable, and refer on to the next appropriate service if needed [source: FFT LLC deck 2024–25].
• Steps [synthesis]:
  1. Review the gains against the family-focused problem definition.
  2. Credit each member's contribution, using the theme.
  3. Confirm the relapse plan and the supports.
  4. Make any onward referral, for example to individual treatment for a member's own mental health needs.

Implementation

4.32 Supervision, adherence and measurement feedback

• Purpose: keep fidelity (adherence plus competence) and outcomes on track. Higher fidelity is associated with better outcomes [source: FFT LLC deck 2024–25; Alexander 2012].
• Steps:
  1. Bring cases to weekly consultation or supervision.
  2. Complete the programme's tracking system: the CSS (FFT LLC) or the TAM and FAM (Sexton).
  3. Use the session-by-session feedback on alliance and phase goals to decide your next move [source: Sexton FFT Associates 2019].
  4. Name your own drift dimensions and track them openly ("transparency with rigor") [source: Alexander 2012].
• Watch for:
  • billable-hours pressure displacing the outcome focus
  • not tracking, which leads to "entropy" and possible iatrogenic effects [source: Alexander 2012]

5. Handling problems

Tags show the source. The most specific source for problem handling is Alexander's (2012) list of common problems. Much of the rest is [synthesis].

• Only some members turn up.
  • Don't settle for whoever attends [source: Alexander 2012].
  • Phone every major player, offer home and out-of-hours times, and keep phoning between early sessions [source: Alexander 2012; Sexton & Alexander 2000].
  • Treat the absent member's stance as relational information. Bring them into the theme ("Dad's staying away might be his way of not making things worse") [synthesis].
• Early dropout risk (hopelessness, high blame, a parent who "wants someone else to parent" [source: FFT LLC deck]).
  • Front-load sessions.
  • Focus sessions 1–2 on balanced alliance and relational reframes. Early change in the parent–youth alliance predicts completion [source: Alexander 2012].
  • Reframe giving up as exhaustion after many failed attempts [synthesis].
• Hostile, escalating sessions.
  • Interrupt and divert. Name the tension, focus on one member, keep reframing, and don't get pulled into reactivity [source: Sexton 2011; Alexander 2012].
  • If safety is at risk, end the joint part of the session and see members separately briefly, then reconvene [synthesis].
• A reframe is rejected. Refine it, or apologise for misunderstanding and move on [source: Hess 2020]. Check that you acknowledged the negative first [source: Alexander 2012]. Try a broader relational theme, which is easier to build than a specific reframe [source: Alexander 2012].
• Relabeling passed off as reframing; blaming language left unaddressed. These are named common errors [source: Alexander 2012]. Fix: add the relational motive, and respond to every blaming statement with validation plus a reframe.
• Therapist drift toward one member or toward an individual focus. Common, and linked to dropout [source: Alexander 2012]. Track who you talk to. In supervision, review session recordings for balance [synthesis].
• Therapist imposing their own view of what the family "really wants". A named problem [source: Alexander 2012]. Return to observed sequences, and test themes as hypotheses.
• Homework not done (non-adherence).
  • Treat it as information: the task was too big, motivation is not yet secure, or the task conflicted with a relational function [synthesis].
  • Shrink the task so it has a high expectation of success [source: Alexander 2012]. Go back to motivation work if blame has returned [synthesis].
  • Never shame the family over non-completion.
• Stuck in behaviour change.
  • Check whether the plan requires changing a relational function rather than serving it, and redesign it [source: Alexander 2012 principle; application is synthesis].
  • Check whether blame or hopelessness has returned, and if so step back into motivation work. The phases are not one-way [synthesis].
• Alliance rupture with one member. Acknowledge it directly, validate their view of you, and reframe their reaction as protective. Rebalance by giving them airtime first next session [synthesis].
• Clinician's view on seeing parents first. Straus (2011) suggested meeting parents alone first. Sexton defended starting with the whole family as more respectful and relational [source: Sexton 2011]. Keep conjoint sessions as the default. Brief separate contact is a deviation to discuss in consultation [synthesis].
• Disclosure of abuse, domestic violence or a lethal risk.
  • Lethality comes first, for example a child-abuse investigation or substance toxicity [source: FFT LLC deck].
  • Follow mandatory reporting and safeguarding procedures. Don't reframe violence or abuse as well-meant, and don't hold joint sessions where a member is unsafe [synthesis].
• Emerging suicidality, psychosis or severe psychiatric illness. These are exclusion criteria when they are the primary need [source: FFT LLC deck]. Do a standard risk assessment, make a safety plan, and refer for specialist care. Restrict lethal means through safe storage or removal, with the family's involvement. Decide in consultation whether FFT should continue [synthesis].
• Youth removed from home mid-treatment (remand or placement). A scheduled removal is an exclusion [source: FFT LLC deck]. Liaise with the system and plan to resume when the youth returns [synthesis; uncertain how FFT LLC handles it].
• Competing or conflicting services. Check whether services running at the same time interfere [source: FFT LLC deck]. Coordinate through team meetings [source: Sexton FFT Associates 2019]. Agree a single lead plan.
• Cultural mismatch or interpreter use. Language delivery is an accommodation. Changing phases or sequence is an adaptation and needs discussion with your FFT consultant [source: Alexander 2012]. Match framing to the family's values [source: EPISCenter 2014].
• Mandated, coerced families (e.g. via court or probation). Reframe the mandate as a shared goal to get the system out of the family's life. Be transparent about reporting to the referrer [synthesis].
• A parent's own serious mental health or substance problem. One FFT source frames a parent's anxiety as the parent's own issue to address [source: Sexton 2011]. Make a parallel referral, and keep the parent in family sessions as long as they can take part [synthesis].
• Agency pressure toward billable hours over outcomes; no tracking. Named problems [source: Alexander 2012]. Use the CSS or TAM data in supervision.

Sources

Sources:

• Functional Family Therapy (OJJDP Juvenile Justice Bulletin, Sexton & Alexander, Dec 2000, NCJ 184743)
• Innovating, Accommodating, Adapting, and Adopting FFT (J. F. Alexander, Blueprints conference, 12 April 2012)
• FFT clinical model slide deck (FFT LLC, Midouhas & Segars, c. 2024–25; Colorado HCPF)
• Functional Family Therapy Logic Model, rev. April 2014 (EPISCenter, Penn State, with FFT Inc.)
• Kansas DOC copy of the FFT logic model
• FFT overview and Clinical Measurement System 3.0 (Sexton FFT Associates, 2019; NYC ACS RFP handouts)
• Functional Family Therapy, CSA Symposium 2020 (S. Hess, United Methodist Family Services; Fairfax County)
• From Conflict to Alliance (T. Sexton, with commentary by M. Straus, Psychotherapy Networker, May/June 2011)
• Functional Family Therapy: A New Road Map for Behavioral Change (T. Sexton, Psychotherapy Networker, 2015)
• Functional Family Therapy: Principles of Clinical Intervention, Assessment, and Implementation (Sexton, Alexander et al. 2002, NCJRS abstract)
• Functional family therapy for antisocial behaviour in adolescents (Robbins & Alexander 2021, Cambridge chapter page; abstract only)
• Functional Family Therapy (Foundations UK Guidebook)

Further reading (not drawn on):

• Alexander, J. F., & Parsons, B. V. (1982). Functional Family Therapy. Brooks/Cole.
• Sexton, T. L. (2011). Functional Family Therapy in Clinical Practice. Routledge.
• Alexander, J. F., Waldron, H. B., Robbins, M. S., & Neeb, A. A. (2013). Functional Family Therapy for Adolescent Behavior Problems. APA.
• FFT LLC clinical training manual (available to trained sites; Alexander 2012 notes it is available on request).