Attachment-based Family Therapy Research Articles

Emotional arousal and reflective functioning among parents participating in attachment-based family therapy for LGBTQ+ young adults and their nonaccepting parents

Objective Parents’ rejection of their LGBTQ + young adults can have a negative impact on their young adult’s psychological welfare, and on the young adult-parent relationship. Parents’ ability to reflect on their child’s pain and unmet needs is thought to evoke empathy and compassion, and reduce rejection. Empirical and clinical evidence suggest that parents’ level of reflective functioning (RF) is impacted by their level of emotional arousal (EA). This study examined the association between parents’ EA and RF within the context of attachment-based family therapy for nonaccepting parents and their LGBTQ+ young adults. Methods 43 therapy sessions drawn from six different cases were coded for parental RF and EA, based on 30-second segments. This generated a total of 343 observations for analyses. Results Hierarchal linear modeling revealed that parents’ level of RF was a function of their concomitant EA, with moderate levels of arousal predicting the highest RF levels. Conclusion Moderate EA may facilitate optimal parental reflective functioning. With nonaccepting parents, who typically present for treatment with high levels of maladaptive fear and shame, therapists would do well to assess their level of arousal and, when indicated, employ downregulating interventions before inviting them to reflect on their young adult’s experience and needs.

Do they cross the bridge when they come to it? Young adult's engagement in attachment‐based family therapy as part of inpatient care

AbstractAlthough attachment seems to be ‘in fashion’ when it comes to discussing mental health issues, there are few evidence‐based therapy models treating attachment issues related to psychopathology. In this paper, we will briefly introduce Attachment‐Based Family Therapy (ABFT) as an evidence‐based intervention for depressed and suicidal adolescents, and its first‐time large‐scale application and implementation in a young adult inpatient care unit. We present our clinical data showing that 98% of the young adults who were proposed ABFT engage into this therapy. In our discussion we briefly describe accommodations to the young adult (YA) age and the inpatient setting and discuss hypotheses about which characteristics of young adulthood, the ABFT core interventions and the residential setting play a role in this high engagement. We discuss how adopting a shared clinical attachment‐based framework as a team might broaden the impact.

Effectiveness of family-based therapy for depressive symptoms in children and adolescents: A systematic review and meta-analysis.

Early-onset depression contributes significantly to the global health burden and has long-term negative effects. This meta-analysis collates and examines the effectiveness of family-based interventions, where family members are involved in the treatment of depression in children and adolescents. A literature search was performed up to 8th March 2023. Randomised controlled trials of family-based interventions were included for participants aged 3-18 years with a diagnosis of major depressive disorder or dysthymia, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) or with a score above a cut-off on a standardised self-report depression measure. The overall effect size for treatment versus active control was g = 0.22 (95% confidence interval [CI]: -0.05-0.50) (nine studies; 659 participants), and for treatment versus non-active control it was g = 0.46 (95% CI: -0.09-1.01) (four studies; 385 participants). Effect sizes were not statistically significant, and heterogeneity was high, ranging between I2 = 64.3-81.1%. Subgroup analysis comparing attachment-based family therapy with family therapy using other theoretical frameworks did not yield a significant difference between the two. The effects of family-based therapies were larger than those in the comparison groups, but family-based therapy did not demonstrate a significant treatment benefit compared to the controls. More randomised controlled trials are warranted, considering that evidence for other psychotherapies for depression in children and adolescents, indicates modest effects. Family-based therapy may be an alternative for children and adolescents whose needs are not addressed by these treatments.

Attachment-Based Family Therapy to Improve Family Functioning in Adolescent Binge-Spectrum Eating Disorders: An Initial Evaluation Via Case Series Design.

Binge-spectrum eating disorders (EDs; bulimia nervosa, binge eating disorder) often develop during adolescence and are associated with serious psychological and physical consequences. Current treatments for adolescents are highly behavioral in nature and while efficacious, many patients do not reach remission indicating that current treatments fail to target a key maintenance factor for EDs. One potential maintenance factor is poor family functioning (FF). In particular, high family conflict (e.g., arguing, critical comments) and low family cohesion (e.g., warmth, support) are known to maintain ED behaviors. Poor FF can (1) cause or exacerbate an adolescent's use of ED behaviors to cope with life stress and/or (2) inhibit parents from being a resource to adolescents during ED treatment. Attachment-Based Family Therapy (ABFT) is specifically designed to improve FF, and thus may be a promising adjunct to behavioral ED intervention strategies. ABFT, however, has not been tested in adolescents with binge-spectrum EDs. Thus, the current study is the first to evaluate a 16-week adapted ABFT treatment for adolescents with EDs (N = 8, Mage = 16.00, 71.43% female, 71.43% White) fusing together behavioral treatment for EDs with ABFT for highest possible impact. Eight families were treated in an open pilot trial to examine treatment feasibility, acceptability, and preliminary efficacy on FF and eating pathology. Overall, findings were promising. ABFT + B treatment was feasible and acceptable and showed preliminary evidence that it could improve FF and ED behaviors. Future research will test this intervention in a larger sample and further examine the role of FF in maintaining ED symptoms.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety.

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Middle childhood attachment-based family therapy: Theory and model description.

In middle childhood, the first manifestations of mental health problems can emerge and become a precursor of mental health issues in adolescence. Given that weak parent-child attachment can contribute to this distress, it is possible that strengthening the attachment bond could reduce risk trajectory. Unfortunately, evidence-based attachment-focused interventions are lacking at this age. Attachment-based family therapy (ABFT) is a well-studied intervention for troubled adolescents and has the potential to be extended downward to children. However, ABFT for adolescents focuses on mentalization and trauma conversation strategies that may be developmentally advanced for children's capacities. Therefore, we modified the intervention strategies to be more developmentally sensitive to childhood. Middle childhood ABFT (MCABFT) builds on the theory that insecure attachment develops through a learning process that can be interrupted and reorganized to promote secure attachment development. MCABFT uses less conversation and more play and puts parents more at the center of the therapy compared with ABFT for adolescents. In this article, we describe MCABFT's theoretical and clinical model.

Adolescents Problem Behaviors during COVID-19: Types, Risk Factors, and Interventions

COVID-19 has brought many issues to our society. One among them is the problem behaviors in adolescents. Compared to adults, adolescents are more vulnerable to both the virus and stressors brought by the pandemic. This article focuses on adolescents problem behaviors during the COVID-19 pandemic. Based on previous studies, we analyze four types of problem behaviors that are prevalent during the pandemic in depth depression and anxiety, suicidal ideation, internet addiction, and truancy. According to their definitions, we categorize depression, anxiety, and suicidal ideation as internal problem behaviors, and internet addiction and truancy as external problem behaviors. The risk factors and intervention strategies are also discussed in line with existing research. Risk factors are discussed from the individual (big five personality traits and self-control strength), family (family relationship), and school aspects (interpersonal relationship and academic stress). Intervention strategies are also explored at individual, family, and school levels. Interventions discussed in this article include logotherapy, physical activities, attachment-based family therapy, and peer education.

The effect of intervention of the developed attachment-based family therapy program in improving the relationship of depressed and anxious adolescents with their parents

The effect of intervention of the developed attachment-based family therapy program in improving the relationship of depressed and anxious adolescents with their parents

22.3 Attachment-Based Family Therapy for Youth at Risk for Suicide: The Next Evolution

Attachment-based family therapy (ABFT) is a manualized, empirically supported family therapy model designed to target family and individual processes that might cause or reinforce adolescent suicide and depression. It is a trust-based, emotion-focused, brief psychotherapy that aims to repair attachment ruptures and rebuild an emotionally protective, secure-based parent-child relationship. ABFT has received 15 years of outcome and process research (Diamond et al, 2022). The model is now well-established and used extensively nationally and internationally.

FASE-family and social engagement model for prevention and management of self harm behavior-a study protocol for cluster randomized control trial in India.

BackgroundSuicide is a substantial public health concern for countries worldwide. Effective preventive and curative interventions for self-harm behavior (SHB) are imperative for nations with an alarmingly high rate of suicide and self-harm behaviors. The intervention protocol named FASE (Family and Social Engagement) consists of comprehensive assessment, Attachment-Based Family Therapy (ABFT), and community linkages for people presenting with suicide or self-harm in emergency departments of tertiary hospitals.MethodsThis article reports the design and protocol for a cluster randomized control trial for suicide prevention and management. After the developed intervention is pilot tested in a tertiary hospital in Kerala, the intervention will be scaled up to be implemented in various tertiary hospitals in Kerala. Each hospital emergency department will be considered a cluster, and these clusters will be randomized to the intervention group and control group in a 1:1 ratio. The eligible people from the intervention clusters will undergo a baseline assessment, a structured moderate intense intervention with twelve sessions spread across 6 months by the trained social workers supervised by the Mental health team, and a follow-up assessment at the end. Participants will be recruited after obtaining consent and explaining the study. The primary outcome includes suicidality measured by the Depressive Symptom Inventory–Suicidality Subscale (DSI-SS), Depression, Anxiety and Stress Scale (DASS), MOS Social Support Survey, and Brief resilience scale (BRS).DiscussionKnowledge generated from this trial can significantly affect new programmatic policy and clinical guidelines that will improve the reduction of suicide rates in the country.Trial registrationProspectively registered in Clinical Trial Registry India (ICMR-NIMS) on 18/10/2021 (ref number- REF/2021/10/048264).

Repairing attachment in families with depressed adolescents: A task analysis.

This exploratory pilot study (N = 3 sessions, 793 speech units) used task analysis to refine an early model of the attachment task in attachment-based family therapy (ABFT).The attachment task aims to repair long-standing parent-adolescent relational ruptures that inhibit parents from beinga resource for adolescents recovering from depression and/or suicidality. Video recordings of three attachment task sessions with strong adherence to the model were selected for intensive study. Two sessions were rated as successful (i.e., attachment was repaired) and one as unsuccessful (i.e., attachment repair did not occur). Sessions were then coded using Structural Analysis of Social Behavior (SASB). The current SASB analysis provided empirical support for our previous clinical impression that the task involves three parts: (I) adolescent disclosure of attachment rupture, (II) parent disclosure, and (III) a more mutual conversation. SASB also provided insights into more subtle elements of the model. Successful attachment sessions were associated with high parent affiliation and autonomy-both while affirming the adolescent's story and when disclosing their own experience. Unsuccessful task attempts were associated with parental enmeshment and hostile belittling, blaming, and distancing. An enhanced model of ideal parent behaviors during the attachment task is offered, including space for parent disclosure-perhaps even apology-that is both warm and independent, leading to a more mutual parent-adolescent conversation. Clinically, the findings support the importance of the therapist focusing on the process and quality of parent-child interactions to facilitate attachment repair.

Increased family cohesion mediates therapist adherence to the attachment task and depression outcomes in attachment-based family therapy

Increased family cohesion mediates therapist adherence to the attachment task and depression outcomes in attachment-based family therapy

Parents' reflective functioning and their agreement on treatment goals in attachment-based family therapy for sexual and gender minority young adults and their nonaccepting parents.

This study examined the trajectories of parents' reflective functioning over the course of individual preparatory sessions with the therapist in attachment-based family therapy (ABFT) for Israeli sexual minority young adults and their nonaccepting parents, and whether such reflective functioning was associated with parents' agreement on the goals for subsequent conjoint corrective attachment sessions.Three parents with good agreement on treatment goals were compared to three parents with poor agreement on treatment goals. Parents' in-session reflectivity regarding their child's experience of nonacceptance, and regarding the quality of their relationship with their child, was observationally measured at the session level.Reflective functioning increased over time among those parents who reported good agreement with the treatment goals. There were no changes in parents' reflective functioning in the poor agreement group.Findings suggest the potential importance of facilitating parents' reflective functioning in ABFT, before conducting conjoint corrective attachment sessions. Research and clinical implications are discussed.

Anxiety-related difficulties in goal-directed behavior predict worse treatment outcome among adolescents treated for suicidal ideation and depressive symptoms.

Although treatments for youth at risk for suicide have been successful, they are not similarly effective for everyone. Anxiety may interfere with adolescents' ability to engage with therapy and explain why some adolescents do not respond as well as others to treatment. The current study tested whether an anxiety diagnosis predicted treatment outcome among a sample of adolescents with suicidal ideation and depressive symptoms participating in either attachment-based family therapy or family-enhanced nondirective supportive therapy (N = 129; M age = 14.87, SD = 1.68; 81.9% female). The data set that the current study used had a high representation of Black/African American adolescents (48.8% of sample), which is valuable, as few studies have included adequate representation of this population. A significant indirect effect (.88; 95% confidence interval [.01, 2.64]) showed that across both treatment conditions, participants who met criteria for an anxiety disorder had greater difficulties engaging in goal-directed behavior midtreatment, and these difficulties, in turn, predicted more posttreatment suicidal ideation. The effect of anxiety on treatment outcome via difficulties with goal-directed behavior was nonspecific to the treatment condition. However, attachment-based family therapy was superior to family-enhanced nondirective supportive therapy in improving this aspect of emotion regulation among adolescents who did not have anxiety. In addition, difficulties with goal-directed behavior on treatment outcome were worse for adolescents' who reported greater attachment avoidance to their parents. Future research should test whether targeting goal-directed behavior and attachment avoidance would result in better treatment outcome for adolescents with suicidal ideation and anxiety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Nurses' experiences of working in the community with adolescents who self-harm: A qualitative exploration.

WHAT IS KNOWN ON THE SUBJECT?: Nurses' experience challenges of managing risk, boundaries and emotional responses when working with people who self-harm. Adolescent self-harm is a growing problem, with rates increasing in the UK. Existing research has failed to differentiate and specifically explore nurses' experiences of working with adolescents who self-harm. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides an understanding of the impact of working with adolescents who self-harm in the community on nurses, and highlights recommendations to improve staff and patient experiences and care. Community CAMHS nurses experience personal and professional conflicts when working with adolescents who self-harm. They experience interpersonal conflicts balancing the needs of adolescents with the needs of the systems around them, and intrapersonal conflicts regarding experiencing mixed emotions, and balancing the care they want to provide with service pressures. Community CAMHS nurses experience feelings of self-doubt and shame due to their emotional responses, self-care behaviours, personal and professional boundaries. They use their feelings of pride, honour and enjoyment to manage these experiences. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses working in CAMHS should be provided with more opportunities for reflective practice and self-care, to enable reflection and learning regarding the emotional impacts and working with systems. Managerial investment is required to facilitate this. Nurses working with adolescents who self-harm in CAMHS could benefit from training regarding understanding and managing self-harm (such as dialectical behavioural therapy), and effectively working with families and people who support these adolescents (such as attachment-based family therapy). ABSTRACT: Introduction Nurses often work in the community with adolescents who self-harm. There is a lack of qualitative research exploring nurses' experiences of working with adolescents who self-harm. Aim This study aimed to gain an understanding of community nurses' experiences of working with adolescents who self-harm. Method Ten semi-structured interviews were conducted with registered nurses working in Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom (UK). Results Data were analysed using interpretative phenomenological analysis (IPA). Two superordinate themes were identified, each consisting of two subordinate themes: personal and professional conflicts, describing interpersonal and intrapersonal conflicts the nurses experienced working with adolescents who self-harm and the systems around them, and personal and professional development, outlining processes of management of conflicts and development. Discussion Nurses feel conflicted about working with adolescents who self-harm within the context of working with systems surrounding the adolescent. They report positive experiences, which they use to reframe their experiences and feelings of shame as a result of their emotional responses, self-care behaviours and personal and professional boundaries. Implications for Practice Nurses working with adolescents who self-harm would benefit from training, reflective practice and self-care. CAMHS managers should encourage and invest in these areas.

Family Treatments for Individuals at Risk for Suicide.

Background: This PRISMA scoping review explored worldwide research on family-based treatments for suicide prevention. Research on this topic highlights the importance of facilitating familial understanding of a suicidal individual. Aim: The review sought evidence of outcomes of trials in which both the patient and family member in the intervention arm attended the same sessions at which suicide was openly discussed. Method: To explore this topic, the authors searched for randomized and nonrandomized controlled trials using Medline (Ovid), PsycINFO (Ovid), Social Services Abstracts (EBSCO), and Web of Science on July 8, 2020. Results: Ten different studies were included that spanned five treatment modalities. Specifically, of the interventions in these 10 articles, 40% employed some sort of cognitive-behavioral therapy, 20% examined attachment-based family therapy, 20% used family-based crisis intervention, and the remaining 20% were distinct interventions from one another. Additionally, several of these articles demonstrated rigorous study methodology and many of the articles reported significant improvements in suicidal ideation or behaviors. Conclusion: Several important research gaps were identified. While this approach has been largely understudied, and to date has been primarily researched in adolescent populations, family interventions have great potential for treatment and prevention of suicidality.

73.4 LEVERAGING FAMILY STRENGTHS DURING CRISIS: TOOLS FOR THE BUSY OUTPATIENT PSYCHIATRIST

Strategies that boost the caregiving capacity of families dealing with childhood mental disorders have a clinically significant impact on health outcomes. Despite their proven efficacy in childhood mental illnesses like depression, disruptive behaviors, psychosomatic illness, anorexia, and substance abuse, family interventions tend to be underutilized and underemphasized during training. Our objective is to highlight the feasibility of implementing family-based interventions in outpatient practice and add to the child and adolescent psychiatrist’s toolkit in crisis situations. The case of an adolescent outpatient with a complex family background—sibling with autism spectrum disorder, death of mother, father with depression, and history of somatoform disorder presenting with depression, self-injurious behavior, and suicide attempts (including one after COVID-19 exposure)—precipitating multiple emergency department visits, psychiatric admissions, and consultation-liaison involvement will be presented. The case will be used to illustrate techniques from attachment-based family therapy (ABFT), as treatment tools to engage family strengths in times of crisis. The ABFT adolescent alliance task was used to increase the youth’s awareness of sadness and anger at the death of her mother and the caregiving role she played for her brother while navigating difficult social dynamics at school. The parent alliance task allowed the father to share his worries about keeping his job while single-parenting a child with special needs and another with significant socioemotional needs. The father’s increased empathy about the youth’s lived experience helped to decrease demands on the youth and defuse conflict. Modifiable family factors, such as conflict, are well-established correlates of youth mental illness and present powerful opportunities for intervention. Evaluating youth perceptions of negative family environments and communication styles (eg, parental criticism) during clinical care, acutely and throughout monitoring, helps clinicians select treatment strategies to optimize the treatment response. Attention to family processes, leveraging family strengths, and decreasing the stresses of a negative family environment can contribute to better treatment engagement and retention, reduce hospitalization rates, and increase adherence to medication.

BRINGING FAMILIES TOGETHER IN CRISIS: FAMILY-BASED INTERVENTIONS ACROSS DIFFERENT SETTINGS OF CARE

There is considerable evidence for the clinical utility of family-based interventions (FI) in several domains of childhood psychopathology. Despite the known efficacy of FI, many child and adolescent psychiatry fellowship programs in the United States provide minimal FI training. The goals of this presentation are to highlight the feasibility and relevance of FI across acute care settings and crisis situations, and to provide practical tips on incorporating FI within the scope of daily practice of child and adolescent psychiatry. Presenters from different institutions across the country will discuss the role of FI in treating youth in crisis from inpatient, consultation-liaison, outpatient, and emergency department (ED) perspectives. Using a case-based approach, presenters will give real-life context for the following treatment approaches: brief family therapy for adolescents in the inpatient psychiatric unit, family CBT to treat psychological distress in children on a transplant unit, attachment-based family therapy (ABFT) for high-risk adolescents in the outpatient setting, and emotionally focused family therapy (EFFT) for suicidal adolescents in the ED. The presenters will engage the audience by incorporating a think/pair/share activity to practice problem solving in each treatment setting, and by providing clinical pearls for clinicians to apply FI skills in their practice. Family factors frequently play a significant role in childhood mental health crises. The presenters demonstrate how FI can be effective practical treatment tools for psychiatrists to apply across treatment settings. Family dynamics represent a critical underpinning in understanding both childhood mental distress and well-being. Therefore, it is critical for child and adolescent psychiatrists to understand how family dynamics affect patient distress and to be equipped with skills to intervene with families across treatment settings.

Implementing Attachment-Based Family Therapy for Depressed and Suicidal Adolescents and Young Adults in LGBTQ+ Services.

Background: Suicide is a serious public health problem for LGBTQ+ adolescents and young adults. Attachment-based family therapy (ABFT) is one of the few suicide treatment models that has been tested with this population. The challenge remains in how to implement ABFT into the ecology of LGBTQ+ service settings. Aims: In this study, we tested the feasibility, acceptability, and preliminary effectiveness of ABFT in LGBTQ+ community settings. Method: Ten participants were enrolled in 16 weeks of ABFT across three LGBTQ+ organizations. Feasibility (treatment completion) and acceptability (Working Alliance Inventory [WAI]; opinions about treatment [OAT]) were measured for youth and caregivers. Depression and suicide outcomes were assessed for nine participants. Results: ABFT was demonstrated to be both feasible and acceptable. All participants completed treatment, and there were no dropouts. Adolescents/young adults and their caregivers reported high WAI and adequate OAT scores throughout treatment. There was a significant decrease in suicidal ideation (β = -12.16, t(10) = -3.14, p < .01). Decreases in depression, however, were not significant (β = -1.83, t(9.11) = -0.88, p = .40). Limitations: The small sample limits our ability to estimate treatment effectiveness. A larger effectiveness trial is warranted. Conclusion: ABFT is a promising treatment for LGBTQ+ service settings.

Demonstrating Attachment-Based Family Therapy for Transgender and Gender Diverse Youth with Suicidal Thoughts and Behavior: A Case Study.

Suicide is a growing public health issue among adolescents. While the majority of transgender and gender diverse (TGD) youth are healthy, many experience suicidal thoughts and behavior (STB). Due to discrimination and stigma, TGD youth attempt suicide at higher rates then heterosexual, cisgender and even cisgender, LGBQ youth. Despite this vulnerability to suicide, few treatments have been developed and tested for this population. One treatment, attachment-based family therapy (ABFT) has been adapted to work with LGBQ youth and may be promising for TGD adolescents at risk for suicide. This article provides an overview of our ABFT modifications for TGD youth with thoughts of suicide. Specifically, we illustrate how treatment outcomes, in a single case study, relate to processes within clinical treatment tasks. The case study demonstrates the application of these ABFT modifications with a self-identified, gender nonconforming adolescent (who had recently attempted suicide) and his caregivers. Treatment evaluation measures were collected over the course of 24 weeks to illustrate the youth's clinical progress. The youth's suicidal symptoms diminished markedly by the end of treatment. Further, the family reported an increased ability for problem solving and more open communication by treatment conclusion.