discussion reflection week 5 disorder application

Please read the article and the two chapters.Prepare a substantive response to the following:

Which of the disorders discussed this week have you (or do you think you will) come across working with your population of interest? Why? (choose only one or 2 disorders)
What factors will you have to consider in assessing the disorders covered this week? How might this disorder present differently based on age, culture, and other contextual factors?
How will you apply what you have learned from the content this week to help individuals with the disorders covered this week?
Cite information from your weekly readings in your response.
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/273701928Attachment-based family therapy for depressed and suicidal adolescents:theory, clinical model and empirical supportArticle  in  Attachment & Human Development · March 2015DOI: 10.1080/14616734.2015.1006384 · Source: PubMedCITATIONS64READS3,4043 authors:Some of the authors of this publication are also working on these related projects:Improvements in Mentalizing as a Mechanism of Change in Psychotherapy for Depressed and Suicidal Adolescents View projectSocioeconomic status, adolescent father avoidance, and perceived burdensomeness predict dropout in a sample of depressed and suicidal adolescents. View projectE. Stephanie Krauthamer EwingDrexel University29 PUBLICATIONS   998 CITATIONS   SEE PROFILEGuy DiamondDrexel University102 PUBLICATIONS   3,394 CITATIONS   SEE PROFILESuzanne LevyDrexel University46 PUBLICATIONS   1,602 CITATIONS   SEE PROFILEAll content following this page was uploaded by Suzanne Levy on 23 March 2015.The user has requested enhancement of the downloaded file.
This article was downloaded by: [Drexel University Libraries]On: 23 March 2015, At: 11:17Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UKClick for updatesAttachment & Human DevelopmentPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rahd20Attachment-based family therapy fordepressed and suicidal adolescents:theory, clinical model and empiricalsupportE. Stephanie Krauthamer Ewingab, Guy Diamondab & SuzanneLevyaba Drexel University, Center for Family Intervention Science,Philadelphia, PA, USAb Drexel University, College of Nursing and Health Professions,Philadelphia, PA, USAPublished online: 17 Mar 2015.To cite this article: E. Stephanie Krauthamer Ewing, Guy Diamond & Suzanne Levy (2015):Attachment-based family therapy for depressed and suicidal adolescents: theory, clinical model andempirical support, Attachment & Human Development, DOI: 10.1080/14616734.2015.1006384To link to this article: http://dx.doi.org/10.1080/14616734.2015.1006384PLEASE SCROLL DOWN FOR ARTICLETaylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Attachment-basedfamilytherapyfordepressedandsuicidaladolescents:theory,clinicalmodelandempiricalsupportE.StephanieKrauthamerEwinga,b*,GuyDiamonda,bandSuzanneLevya,baDrexelUniversity,CenterforFamilyInterventionScience,Philadelphia,PA,USA;bDrexelUniversity,CollegeofNursingandHealthProfessions,Philadelphia,PA,USA(Received18March2014;accepted5May2014)Attachment-BasedFamilyTherapy(ABFT)isamanualizedfamily-basedinterventiondesignedforworkingwithdepressedadolescents,includingthoseatriskforsuicide,andtheirfamilies.Itisanempiricallyinformedandsupportedtreatment.ABFThasitstheoreticalunderpinningsinattachmenttheoryandclinicalrootsinstructuralfamilytherapyandemotionfocusedtherapies.ABFTreliesonatransactionalmodelthataimstotransformthequalityofadolescent–parentattachment,asameansofprovidingtheadolescentwithamoresecurerelationshipthatcansupportthemduringchallengingtimesgenerally,andthecrisesrelatedtosuicidalthinkingandbehavior,specifically.Thisarticlereviews:(1)thetheoreticalfoundationsofABFT(attachmenttheory,modelsofemotionaldevelopment);(2)theABFTclinicalmodel,includingtrainingandsupervisionfactors;and(3)empiricalsupport.Keywords:attachment-basedfamilytherapy;suicide;depression;treatment;adolescenceDepressionisasignificantproblemamongyouth.Elevenpercentofadolescentshaveadiagnosabledepressivedisorderbyage18,anditishighlyco-morbidwithadolescentsuicideriskNationalInstituteofMentalHealth(NIMH,2014).Eachyear,approximately20%ofteenagersseriouslyconsiderkillingthemselves(Nocketal.,2013).Overonemillionteenagers(5–8%)attemptsuicideeachyear,and1600to2000diebysuicide(Grunbaumetal.,2002;Hamilton,Minino,Kochanek,Strobino,&Guyeret,2005).Suicideisthesecondleadingcauseofdeathforyoungpeopleages15–24(Hoyert&Xu,2012).Adolescentdepressionandsuicideriskandtheassociatedisolation,hope-lessnessandhelplessnessareextremelystressfulandpainfulforaffectedteensandtheirfamilies(Lindqvist,Johansson,&Karlsson,2008).Thetraumaticlossofayoungpersonisdevastatingforfamilies,peers,andcommunities(Brentetal.,1989;Gould,Petrie,Kleinman,&Wallenstein,1994).Thereareseveralempiricallysupportedinterventionsfortreatingdepressioninado-lescents(e.g.,cognitivebehavioraltherapy,interpersonaltherapy,andmedication);how-ever,depressedteenswithsignificantsuicideideationhavebeenshowntobeamongthemosttreatmentresistantpatients(Brent,Emslie,Clarke,Wagner,&Asarnow,2008;Curryetal.,2006;TADS,2004).Unfortunately,nomedicationandfewpsychotherapystudieshavefocusedonsuicidalyouth.Existingstudiesdemonstrateonlyaslightreductioninsuicideattemptsorideation,andexperimentaltreatmentshaverarelybeensuperiortotreatmentasusual(Brentetal.,2013;Spirito&Esposito-Smythers,2006).Ingeneral,theefficacyofcognitivebehavioraltherapy(CBT)andotherformsofpsychotherapyfor*Correspondingauthor.Email:sewing@drexel.eduAttachment&HumanDevelopment,2015http://dx.doi.org/10.1080/14616734.2015.1006384©2015Taylor&Francis
suicidalyouthhasbeenmixed,treatmentengagementofadolescentshasbeendifficult,andthedebatecontinuesoverwhethermedicationexacerbatessuicidalthinking(Hammad,Laughren,&Racoosin,2006;Tarrier,Taylor,&Gooding,2008).Clearly,moreresearchisneededonalternativeinterventionapproaches.Family-basedtreatmentsforyouthdepressionandsuicidearepromisingforanumberofreasons.Thedevelopmentandmaintenanceofadolescentdepressionandsuicideriskhasbeenconsistentlylinkedtofamilystressandconflict,andnegativefamilyfunctioning(e.g.,highconflict,lowcohesion,ineffectiveparenting,etc.)isastrongriskfactorforyouthsuicideanddepression(Ehnvall,Parker,Hadzi-Pavlovic,&Malhi,2008;Hardtetal.,2008;Salzinger,Rosario,Feldman,&Ng-Mak,2007;Wagner,1997;Wagner,Silverman,&Martin,2003).Inaddition,familyconflictisfrequentlyanegativemoderatoroftreatmentoutcome(Asarnowetal.,2009;Birmaheretal.,2000;Brentetal.,2008).Forexample,inthelargestadolescentsuicidetreatmentstudytodate,parentreportedmother–childconflictpredictedpooroutcomesat12weeksoftreatment(Feenyetal.,2009).Incontrast,positiveaspectsofthefamilysuchasfamilycohesion,warmth,emotionalsupport,andparentalavailabilityandmonitoringareallprotectivefactorsinpreventingsuicideanddepression(Beautrais,Joyce,&Mulder,1996;Brentetal.,1994;Fergusson,Woodward,&Horwood,2000;Kurtz&Derevensky,1993;McKeownetal.,1998;Resnick,Acierno,&Kilpatrick,1997;Rubenstein,Halton,Kasten,Rubin,&Stechler,1998;Wagneretal.,2003;Zhang&Jin,1996).Asanexample,aftercontrollingforfactorssuchasdepressionandstressfullifeevents,adolescentsdescribingtheirfamiliesasmutuallyinvolvedanddemonstratingahighdegreeofsharedinterestsandemotionalsupportwere3–5timeslesslikelytobesuicidalthantheirpeersfromlessintegratedfamilies(Rubensteinetal.,1998;Rubenstein,Heeren,Housman,Rubin,&Stechler,1989).Overall,theempiricaldataonfamilyfactorssupportsaninterpersonalortransactionaltheoryofadolescentdepressionandsuicide,inwhichenvironmentalandfamilyfactorscaneithercauseorexacerbatethedepressionand/orsuiciderisk(Cicchetti&Toth,1998;Gotlib1992;Hammen,1992;Joiner,Coyne,&Blalock,1999).Thesemodelsdonotignorebiological,temperamental,orcognitivefactors,butviewenvironmentalfactors(especiallyfamilyrelations)asinteractingwithindividualfactorstoplayamajorroleinshapingthedevelopmentalcourseofthedepressionandsuicidalfeelings(Cummings&Davies,2010).Joiner(2009)hasproposedthatthwartedbelongingness(definedasthepainfulpsychologicalstateresultingfromunmetneedstoconnectandbelong)andperceivedburdensomeness(definedasperceptionsthattheworld/others“wouldbebetteroffifIweregone”)maybepartofthepsychologicalfoundationofadesiretokilloneself(VanOrden,Cukrowicz,Witte,&Joiner,2012,p.198).Particularlyforyoungpeople,feelingsofbelongingandburdensomenessareintricatelytiedtothequalityoffamilyrelationships.Unfortunately,beyondparentalpsycho-education,fewtreatmentsfordepressedandsuicidalyouthfocusintensivelyonfamilyfactors.Attachment-BasedFamilyTherapy(ABFT)isapromisingfamily-basedapproachdesignedfortreatingdepressedyouth,includingthoseatriskforsuicide,andtheirfamilies.ABFTisamanualizedempiricallyinformedandsupportedtreatmentwiththeoreticalunderpinningsinattachmenttheoryandclinicalrootsinstructuralandemotionfocusedtherapy(Greenberg,2002;Minuchin,1974).Ithasbeentestedasa12–16weekintervention,butthemodelisflexibleandcanbeadaptedclinicallyasalongertreatment.FourstudieshavedemonstratedthatABFTcanreduceadolescentdepressionandsuicidalideationmoreeffectivelythanwait-listcontroland/ortreatmentasusual(Diamond,Reis,Diamond,Siqueland,&Isaacs,2002;Diamond,Siqueland,&Diamond,2003;Diamondetal.,2010;Israel&2E.S.K.Ewingetal.
Diamond,2012).DataalsosuggestthatABFTiseffectivewiththemosttroubledpopulations,includingadolescentswithcomorbidanxiety,severesuicideideation,ahistoryofmultiplesuicideattempts,and/orahistoryofsexualabuse(Diamond,Creed,Gillham,Gallop,&Hamilton,2012;Diamondetal.,2010).Thesegroupshavetradition-allynotrespondedaswelltocognitivebehavioraltreatmentand/ormedication(Asarnowetal.,2009;Barbe,Bridge,Birmaher,Kolko,&Brent,2004;Curryetal.,2006).Basedonclinicalresearch,ABFThasearnedthedistinctionasanempiricallyprovenprogrambythePromisingPracticesNetwork(www.promisingpractices.net)andhighratings(3.1–4.0outof4.0)intheNationalRegistryofEvidenced-basedProgramsandPractices(http://nrepp.samhsa.gov).TheABFTtreatmentmanualprovidesspecificguidancefortherapistsonhowtoachieveABFT’stherapeuticgoals.Toachievethesegoals,ABFTisorganizedaroundfivetreatmenttasks:(1)TheRelationalReframe;(2)AdolescentAlliance;(3)ParentAlliance;(4)RepairingAttachment;and(5)PromotingAutonomy(Diamond,Diamond,&Levy,2013).Tasksarenotthesameassessions,andtheymaytakeseveralsessionstoaccomplish.Thefivetasksprovidetherapistswithstrategies,principlesandthemestohelpaccomplishthegoalsofeachtask.Therapistadherencemeasuresarealsoavailabletohelpguidetherapistsandsupervisors.Thus,themodelprovidesstructure,butalsoenoughflexibilityfortherapiststoaddresstheidiosyn-craticchallengesthateachfamilybringstotreatment.Similarly,althoughtheprimarystanceofthetherapistinABFTisdirective,inthatthemodelencouragestherapiststouseveryspecificstrategiesandinterventiontechniques,thestrategiesareprincipledriven,andtherapistsareencouragedtousethemflexiblyandsensitivelyintheirconceptualizationandapproachwitheachfamily.Belowwereview:(1)howattach-menttheoryinformsthemodel;(2)thestructureoftheclinicalmodel;and(3)thedatatosupportitsefficacy.TheoreticalfoundationsofABFTAttachmentandadolescentsuicideanddepressionABFTisstronglyinformedbyattachmenttheoryandmodelsofemotionaldevelopmentinchildhoodandadolescence.Attachmenttheory’scentralpremiseisthatchildrenhaveabasicevolutionaryinstincttoseekoutparentsforcareandprotection.Whentheseneedsarenotmet,childrenareatriskfordevelopinginsecureattachment.Whileinsecureattachmentpredictsarangeofmaladaptiveoutcomes,includingdepression,secureattach-mentprotectschildrenandadolescentsandisrelatedtoavarietyofadaptiveoutcomes(Kobak,Rosenthal,Zajac,&Madsen,2007).Thereisgoodevidencefortheimportanceofcontinuedhealthyattachmentrelation-shipsinadolescence(Kobak,Cassidy,Lyons-Ruth,&Zir,2006;Steinberg,1990).Secureattachmentinadolescence,markedbyconfidentexpectationsinacaregiver’savailabilitytoprovidesupport,protectionandguidance,enablesmoredirectparent–teencommunica-tionandconflictnegotiation.Suchdynamicspromoteadolescentperspectivetaking,emotionregulation,andproblemsolvingskillsandprovideadolescentswiththefounda-tionfornegotiatingautonomyandsuccessfullylaunchingintothedevelopmentalperiodofemergingadulthood(Kobaketal.,2006;Kobak,Cole,Fleming,Ferenz-Gillies,&Gamble,1993;Steinberg,1990).Incontrast,insecureattachmentinadolescenceisrelatedtomaladaptiveadolescentoutcomes,includingemotionalavoidance,dysfunctionalanger,andover-personalization,Attachment&HumanDevelopment3
allofwhichincreasetheriskofconflict-filledparent–teenrelationships.Parent–teenconflictsignificantlyincreasestheriskforteendepressionandsuicide(Kobak,Sudler,&Gamble,1991;Marsh,McFarland,Allen,BoykinMcElhaney,&Land,2003).Infact,Brentetal.(1988)foundthat20%ofadolescentsuicidesand50%ofnon-fatalsuicideattemptsweredirectlyprecededbyconflictwithparents.Intermsofspecificattachmentstylesandrisk,childrenclassifiedasanxiouslyattachedhavebeenshowntohaveahigherriskforthedevelopmentofdepressionandsuicidalityinadolescence.Inadolescenceandadulthood,preoccupiedstatesofmindandunresolvedstatuswithrespecttolossorabuse,asassessedbyTheAdultAttachmentInterview,co-occurandprospectivelypredictdepressivesymptomsandareassociatedwithsuicidality(Adam,Sheldon-Keller,&West,1996;Ainsworth,1982;Allen,Porter,McFarland,McElhaney,&Marsh,2007;Chango,McElhaney,&Allen,2009;George,Kaplan,&Main,1996;Greenberg,Siegel,&Leitch,1983;Kobak&Sceery,1988;Kobaketal.,1991;Sund&Wichstrom,2002;West,Spreng,Rose,&Adam,1999).ParentingThequalityofcaregivingisimportanttoparent–childattachmentrelationshipsandthedevelopmentandmaintenanceofchildren’sattachmentsecurity.Whilesupportiveandemotionallyattunedparentingfosterschildren’sattachmentsecurity,parentingthatisrejecting,intrusive,emotionallyunresponsive,orinconsistentputschildrenatgreaterriskforinsecureattachment(vanIjzendorn,1995).Manyfactorsimpactthelikelihoodthatparentswillprovidesensitiveandresponsivecaretochildren,includinglifestressors,parent’sownattachmentexperiences,andotherpsychologicalresources.Forexample,parentaldepressionhasoftenbeenassociatedwithparentingthatisrejecting,critical,highinaffectionlesscontrol,andlowinsupport(Restifo&Bogels,2009).Incontrast,attachmentpromotingparentingisresponsive,emotionallyattuned,anddevelopmentallyflexible,inthatparentsmustadapttheirparentingstrategiestomatchchildren’sdevelopmentalneeds.Parentalflexibilitywithteenagersisparticularlyimpor-tant,asparentsneedtobeawareandresponsivetotheiradolescent’sgrowingneedsforautonomy,whilestayingawareandresponsivetocontinuedattachmentneeds.Forexample,sensitiveparentalresponsestoattachmentneedswithteenagersmaylookdifferentthansensitiveresponsesatearlierstages(i.e.,verbalreassurance,opendiscus-sion,andguidancevs.physicalprotection).Ifparentsareattuned,flexible,andadaptive,itismorelikelythatadolescentdevelopmentalchallengeswillbecomegrowth-promotingopportunitiesforboththeteenandtheparent.However,whenparentscannotadapt,normaldevelopmentalstrugglescanbecometenseandconflict-filled.Astheadolescentbecomesmoredifficult,defiant,and/orwithdrawn,parentsfrequentlyrespondwithincreasednegativeemotionality,perpetuatingacycleofhostility,rejectionandwithdrawal(Micucci,1998;Sheeber&Sorensen,1998).Suchnegativefamilyinteractionalpatternsservetoreinforceadolescentnegativeself-concept,causingorfuelingdepression(Yap,Allen,&Sheeber,2007).Thus,interpersonalvulnerabilitiesoftheparentcancollideandinteractwiththoseoftheteentoplayamajorroleinshapingtheteen’sdevelopmentalcourse,includingtheriskfordepressionandsuicide(Cummings&Davies,2010).Thesestrugglesmaybecomecompoundedwhenthereisahistoryofchronicfamilydysfunctionortrauma-relatedfactorssuchasabuseorneglect.Iftheearlyattachmentenvironmentwasinadequate,childrenmaynothavereceivedthepsychological“mentoring”neededtodevelopadequateintra-andinterper-sonalskillstomanagegrowthandconflict.Withouttheseskills,adolescentscancometo4E.S.K.Ewingetal.
viewtheirparentsandothersasunsafe,untrustworthy,andunreliable,andthemselvesasunworthyofloveandcomfort.Theirinternalworkingmodelsofselfandothersmayincludedefensivestrategiesusedtoprotectthemselvesfromfurtherinterpersonalhurtanddisappointmentratherthanstrategiesforpromotingintimacyandconflictresolution.TheABFTclinicalmodelWithattachmenttheoryasitsbackdrop,ABFTaimstospecificallytargetimportantattachmentprocessesinordertobuildstrongerparent–teenrelationshipsthatcanserveasaresourceandhelpbufferagainstthestressorsassociatedwithadolescentsuicideanddepression.ABFTisdesignedasatransactionalmodelthataimstoimprovefamilyprocessesandparent–teenattachmentthroughindividualintra-psychicworkwithteensandtheirparentsseparately,aswellasthroughinteractionalandinterpersonalworkduringfamilytherapysessions.AcentralpremiseofABFTrestsontheprinciplethatattachment(andcaregiving)isopentorevisionbasedonnewexperiencesacrossthelifespan(Bowlby,1969).Whileresearchsupportstheplasticityofattachment(Waters,Kondo-Ikemura,Posada&Richards,1991),mostchange-focusedstudieshaveexaminedhownegativelifeeventscanleadtodiscontinuityanddisruptionsinsecureattachment.However,MainandGoldwyn(1998)arguethatimprovementsinfeltsecurityandself-perceptioncanoccurwithinthecontextoflatersecurerelationshipssuchasromanticrelationshipsoratherapist/clientrelationship.Withthisinmind,ABFTisdesignedtorevivetheattachmentpromotingfamilyenvironmentasameansofimprovingsecurityandself-perception/self-efficacyintheadolescentandcaregivingefficacyinparents.Thisisaccomplishedbyplacingconversa-tionsaboutattachmentrupturesatthecenterofthetherapeuticconversation.Adolescentsengageinreflective,attachment-focused,andemotion-focusedconversationstargetingtheir“righttobeheardandcaredfor,”byparentsandlovedones,particularlywhenconfrontingthedeeplypainfulexperiencesofhopelessnessanddespairassociatedwithdepressionandsuicide.Specificattentionispaidto“whatgetsintheway”oftheadolescentusingtheirparentforcomfortandhelpduringthesetimes(e.g.,lackoftrust,fearofbeingadisappointment,lackofparentalempathy,etc.).Therapistsconductindividualsessionswithteensandparents,aswellasjointfamilysessions.Intheindividualsessionswithteens,therapistsworktohelpadolescentsincreasetheirawarenessandunderstandingofcoredisappointmentsandrupturesintheirrelation-shipwiththeirparent(s)andtoraisetheirexpectationsforsensitiveandsupportivecare.Intheindividualsessionswithparents,therapistsworktoamplifyparents’caregivingmotivationforateentheyoftenfeelisverydifficult,rejecting,orburdensome.Theworkfocusesonincreasingparents’awarenessoftheirparentingstrategies,influencesonthesesparentingstrategies(e.g.,contextualstress,theirowncaregivingandattachmentexperi-ences,theirchild’sdistress),andtheimportanceofattunementtotheiradolescents’emotionalandattachmentneeds(Belsky,1984).Inaddition,therapistsworkwithparentstoboosttheirknowledgeofspecificemotion-coachingskillstouseinconversationswiththeiradolescent(Gottman,Katz,&Hooven,1996).Infamilysessions,therapistsworktohelpstructurecorrectiveattachmentexperiencesintheformoftherapeuticconversations.Duringtheseconversationsadolescentstalkopenlywiththeirparentsaboutinterpersonalinjuries,whileparentsprovideemotionalsupportandvalidation.Suchconversationsserveasthepowerfulcrucibleforprovidingnewparent–teeninterpersonalexperiences.These“correctiveattachmentexperiences”Attachment&HumanDevelopment5
helpfamiliesworkthoughpastdisappointmentsandhurtswhileofferinganexperienceorinvivoexposuretoamoreattachmentpromotinginteraction(e.g.,adolescentexpresseshurtandparentscomfortandprotect).Overtime,andthroughrepeatedexperiencesofpositiveinteractions,adolescentslearnthattheirparent(s)canbeavailableandresponsivetotheiremotionalneeds,impactingadolescents’internalworkingmodelsoftheirparent-(s)andthemselves.Parents,inturn,receivetherewardofincreasedfeelingsofclosenesswiththeirteenandanimprovedsenseofparentingefficacy.Oncethefamilyhasreestablishedsometrust,therapybeginstofocusonaddressingotherfactorsthathavecontributedtotheteen’sdepressionandonpromotingteenautonomyandengagementinthenormativetasksofadolescence(e.g.,school,employ-ment,sociallife,dating),usingthefamilyasasecurebasetosupporttheseefforts.FivetreatmenttasksABFTusesfivetreatmenttaskstoguidetherapiststhroughthetreatmentprocess.“Tasks”arenotequivalenttosessionsandeachtaskmaytakeoneormoresessions.Thefivetasksinclude:(1)RelationalReframe(usuallyonesession);(2)AdolescentAllianceTask(usually2–4sessions);(3)ParentAllianceTask(usually2–4sessions);(4)RepairingAttachmentTask(usually1–3sessions);(5)AutonomyPromotingTask(usually4–8sessionsinthecontextofa16weektreatment).Table1liststhefiveABFTtasks,theprocessorientedgoalsandtheoutcomefocusedgoals.Theprocessgoalsreflectclinicalmarkersofsuccesswithineachtask.TheoutcomegoalsreflectthecentralpsychologicaldomainstargetedforchangethroughABFT(Table2).Task1Task1,theRelationalReframe,takesplacewithboththeadolescentandparent(s)presentatthefirstsession.Task1isusuallydoneinone60–90minutesession.Reframingisdiscussedinseveralsystemicandcognitivemodelsoftherapy.ABFTtherapistsusethisstrategyaswell,butforaveryspecificgoal:shiftingthefamily’sviewoftreatmentfromfocusingontheadolescentas“theproblem”toenhancementoffamilyrelationshipsasanimportantpartofthesolution.Task1beginswiththetherapistorientingthefamilytosessionandtreatmentgoals(e.g.,“I’dliketospendsometimetodaygettingtoknoweachofyou,whoyouare,whatyouliketodo,andthenI’dliketofindoutmoreaboutwhathasbroughtyoutotreatment,yourunderstandingabout[adolescent’s]depression,andwhatIthinkwillbehelpful.Bytheendoftoday’ssession,I’mhopingthatwecanformanagreementandsomegoalsfortreatment”).Thetherapiststartswithsomebasicjoiningwiththefamily(e.g.,whatdoeseachfamilymemberenjoydoing,discussionofparticularinterests,andstrengths)alongwithbasicinformationgatheringaboutfamilycontext(e.g.,wholivesinthehome,whatkindofneighborhoodtheylivein,involvementofextendedfamilyintheirlives,etc.).Whenthetherapisthasmadeeffortstojoinwitheachfamilymemberandgatheredenoughbasicpreliminaryinformationaboutthefamily,theymakeastatedshifttoassessmentoftheadolescent’sdepression(e.g.,“So,nowI’dliketofindoutalittlemoreaboutwhathasbroughtyouinfortreatment.[Toadolescent],Iknowyou’vebeenstrugglingwithsomedifficultthoughtsandfeelingsrecently.Tellmemoreaboutthat”).Thetherapistbeginstoincreasinglyutilizeemotion-focusedtechniquesatthispoint,workingtoidentify,highlight,andevokeaffectaroundtheadolescent’sexperiencesofhopelessnessanddepression.Thegoalsofthetherapistherearetogettheadolescent“onrecord”asexperiencingsignificantisolationanddespairandtoshowgenuinecareand6E.S.K.Ewingetal.
Table1.ABFTprocessandoutcomegoalsforeachtask.TaskRelationalreframeAdolescentallianceParentallianceRepairingattachmentPromotingautonomyTypicalduration1session2–4Sessions2–4Sessions1–3Sessions4–8SessionsProcessgoalAttributionalshiftinhowfamilymembersviewtheproblemandsolutionBetterunderstandingofattachmentnarrative(i.e.,thoughts,feelings,memories)ShiftintheparentsworkingmodeloftheadolescentandtheirparentingroleEngagementinconversationsthatworkthroughattachmentrupturesParentseffectivelyhelpadolescentsresolvenonfamilybasedproblems(school,job,depression)OutcomegoalAgreementtoparticipateinrelationalfocusedtherapyRevivedvaluingofattachmentandwillingnesstorenegotiateitRevivedcaregivingmotivation;AcquisitionofemotioncoachingparentingskillsRevisedviewofselfandotherandrenewedinterpersonaltrustResumednegotiationofmorenormativeissuesrelatedtoadolescentdevelopmentAttachment&HumanDevelopment7
empathyfortheseexperiences.Atthispoint,therapistsaregenerallyaboutmidwaythroughthesession.Usingtheevokedemotionsurroundingtheteen’sexperiencesofdepression,thetherapistmakesamarkedshiftawayfromassessmentofdepressionandintoanassessmentofattachment.Thiscanbeaccomplishedthroughavarietyoftechniques,oftenbeginningwithquestionsaboutfamilycontributionstotheteen’sdepression.Sometimesthesecon-tributionsarequiteobvious(e.g.,theteenhasopenlydiscussedhowconstantarguinginthehouseisoneofthecausesfornegativemood).Othertimes,familycontributionsappeartobelessdirectlycausaloftheteen’sdepression;ratherfamilyrelationshipsaresimplynotasourceofcomforttotheteenwhentheyarefeelinghopelessandsuicidal.Inthesecasesthepivotalquestionisoftenthe“corequestion”ofABFT,whichis“Whenyouarefeelingsohopelessanddownthatyouarethinkingoftakingyourownlifeorharmingyourownbody,whatgetsinthewayofgoingtoyourmom/dadforhelp?”.ThisquestioniscentraltoTask1,andtooverallABFTcaseconceptualization,andservesseveralpurposes.Firstitshiftsthecontentoftheconversationfrombehavioraldescriptionsandhistorytakingtointerpersonalproblemsoftrust,love,supportandcom-munication.Second,thequestionisofteninstrumentalinelicitingstrongandfrequentlyavoidedemotionsinbothteensandtheirparents.Forexample,ratherthanfeelingindiffer-ent,theadolescentmaybegintoacknowledgethatheorsheisangry,disappointed,orworriedaboutburdeningtheirparent(s).Thetherapistworkswiththeseemotionstobegintoidentifyandbuildlongingintheteenforimprovedconnectionwiththeirparent.Similarly,thetherapistharnessesparentalvulnerableemotionsinthispartoftheconversationtodrawoutandhighlightparents’desireto“dowhateverittakes”tobeasourceofcomfortandguidancefortheirteenwhenheorsheisinpain.Therapistsdonottrytofullyuncoverorunderstandtherelationalrupture(s)inthissession.Instead,theyworktoidentifyenoughtobeabletopunctuatetheconsequencesoftherupture(s)(“Lookthisdivorcesoundsverycomplicated,andIneedtobetterunderstandit.However,whatiscleartomeisthatsincethedivorce,youandyourmotherhavegrownverydistant”).Thetherapistendsthissequencebyexplicitlyaskingtheteenandhisorherparentsfortheiragreementtomakeimprovementsintheirrelationshipandcommunicationthefirstcentralgoaloftherapy.Thefocusupuntilthispointondeepeningaffectandexploringrelationalruptures,togetherwiththetherapist’scommitmenttothegoalofrelationshiprepairandtheiradmirationandsupportoffamilymembers,conveysthetherapist’sleadership,confidenceintheapproach,andcommitmenttosupportandscaffoldeachfamilymember.Whenaskedtomakestrengtheningfamilyrelationshipsthefirstgoaloftherapy,manyfamiliesreportTable2.OverviewofABFTempiricalstudies.StudyNEffectsizedepressionatpost-treatmentEffectsizesuicideatpost-treatmentEffectsizedepressionatfollow-upEffectsizesuicideatfollow-upDiamondetal.(2002)321.21(HAM-D)0.52(SIQ-JR)**Diamondetal.(2010)66.37(BDI-II).95(SIQ-JR).22.97IsraelandDiamond(2012)20.8(BDI-II)1.08(HAM-D)***Diamond,Diamond,etal.(2012)10.90(BDI-II)2.10(SIQ-JR)**Note:*DatanotcollectedforstudyBDI-II=BeckDepressionInventoryII;HAM-D=HamiltonDepressionRatingScale;SIQ-JR=SuicideIdeationQuestionnaire-JR.8E.S.K.Ewingetal.
that,“Notherapisthaseveraskedthisofusbefore.”Theyoftenexpressfeelingreliefandhopethattheyhavebeenofferedapathtoincreasedmutualunderstandingandconnection.Insum,Task1servestoshiftthefocusoftherapyfromfixingtheadolescenttorepairingtherelationalrupturesthathavedamagedtrustinthefamily,withthestatedgoalofpromotingtrust,love,respectandprotectiontorefurbishthecrucibleoffamilysecurity.Ultimately,improvingfamilialsupport,trust,andsecuritywillhelpbufferagainsttheadolescent’sdepression/suicidalideationrelapseandprovidetheadolescentwithanimportantresourcetoturnto,ifandwhenrelapseoccurs.TherapistsaimtogetallfamilymemberstocommittotherelationalfocusoftreatmentinTask1.However,sometimesteensand/orparentsmayexpressresistancetothisplan.Intheseinstances,therapistsscalebacktheirexpectations,knowingthattheywillrevisittheircommitmenttothistreatmentgoalinthecomingindividualsessions;theyaskfamilymemberstoconsidertherelationalfocusasapossibletreatmentgoal,andaskthemtocomebacktothenextindividualparentandteensessions(Tasks2and3),sothattheycancontinuetogettoknowoneanotherandspendmoretimediscussingtreatmentgoals.Thus,themodelisflexibleenoughthattherapistsareabletousetheirassessmentofeachfamily’sneeds,andadaptthepaceandgoalsofsessions,accordingly.Task2Task2,TheAdolescentAllianceTask,usuallyoccursnext(andoftenconcurrentlywithTask3).ThegoalsofTask2aretypicallyaccomplishedintwotofoursessions.CentralgoalsofTask2areto:(1)joinandbondwiththeadolescent;(2)increasetheadolescent’sawarenessandunderstandingofcoredisappointmentsandrelationalruptureswiththeirparent(s)andtheimpactoftheserupturesontheirdepression;(3)raisetheadolescent’sfeelingsofentitlementandexpectationstohavetheirthoughtsandfeelingsheardbytheirparentswithsensitivityandsupport;and(4)preparethemtotalkrespectfullyandassertivelytotheirparentsaboutthesefeelingsandthoughts.Thetherapistbeginswithtryingtostrengthenallianceandtrustthroughexploringtheadolescent’slife(e.g.,friends,school,romanticrelationships,useofdrugsandalcohol,etc.)andhighlightsstrengthsandcompetencieswhenappropriate.Thetherapistthenturnstounderstandingthedepression.Astheadolescentdescribestheirexperienceswithdepression,thetherapistincreasinglyusesemotion-focusedtechniquestohighlightandpunctuatetheirfeelingsofisolationandunhappiness.Withtheadolescent’sdespairfullyelaboratedandonrecord,thetherapistmakesamarkedshiftintheconversationtowardsunderstandingtheimpactoftheadolescent’sattachmentrelationshipsontheirexperiences.Here,thegoalistohelpdeepenunderstandingandarticulationofhowrelationshipbarrierswiththeirparentsaffecttheirexperiencesofdepressionandsuicidalthinking.Therapistsfrequentlyasksomeversionofthefollowingquestions,“Whenyouareinthatverydarkplace,feelingsobadlythatyouarecontemplatinghurtingyourownbody,whycan’tyougotoyourmotherforsupportorhelp?Whyareyounotabletogetcomfortfromtheverypersonwhosejobitistocomfortandsupportyou?”Thecoreofthisconversationfocusesonexploringtheattach-mentrupturesthathavedamagedtrustwithparents.Attachment“injuries”or“ruptures”mayresultfromdepression-relatedstress,ahistoryofnegativeinteractionsandcommu-nication(e.g.,criticism,over-control),traumaticabuse(e.g.,rejection,neglect,orabuse),and/orparentalpsychopathology(e.g.,depression,substanceuse).Thisexplorationinvolvesprobingthestoriesoflossanddisappointment,challengingthedefensesthatminimizetheattachment-rupturingevents,andevokingmoreprimary,oftenavoidedvulnerableemotions.Forsomeadolescentstheprimaryemotionisanger,andforothersitissadness.AstheAttachment&HumanDevelopment9
therapisthelpstheadolescentmakethesestoriesmorecoherent,morecomplex,andmoreemotionallyhonest,adolescentsdevelopagreatertolerancefordifficultemotionsandagreatercapacitytounderstandwhatdrivestheirsuicidalurges.Therapistsharnessthisburgeoningpsychologicalawarenesstoincreasetheadolescent’sentitlementtoexpresstheirfeelingsandtogainanagreementfromtheadolescenttoengageindirectandhonestconversationwiththeirparent(s).Thetherapistmustanticipatethebarriersandresistancetothistreatmenttaskandhelptheadolescentworkthroughtheirambivalenceandhesitation.Adolescentsareoftenworriedthattheirparentswillnotlisten,willrespondliketheynormallydo,willpunishthem,orthattheywillhurttheirparentsiftheysayhowtheyarefeeling.Therapistsassureadolescentsthattheywillhelpthefamilyhaveadifferentkindofconversationandnotjustrehashhurtfuloldconversations.Oncetheadolescentagreestoengageintheattachmenttaskwiththeirparent(s)(Task4),thetherapistworkstopreparetheadolescentwithskillsthatwillbehelpfulfortheseinvivoconversationsaboutattachmentinjuriesandruptures(e.g.,talkingthroughfearedreactions;coachingthemaboutassertivevs.passive/withdrawnoraggressivecommunication).Task3Task3,TheParentAllianceTask,frequentlyoccursconcurrentlywithTask2(i.e.,therapistsmayholdtwosessionsaweekonewithadolescentsandtheotherwiththeirparents).ThegoalsofTask3aretypicallyaccomplishedintwotofoursessions.ThecentralgoalsofTask3aretoreinvigoratetheparent’scaregivingmotivationandtoreshapetheirstrategiesforinteractingwiththeirtroubledteen.Thesegoalsaremetbyprovidingparentswithsupportandempathy,increasingtheirawarenessoftheirparentingstrategiesandinfluencesonthesestrategies(e.g.,contextualstress,theirownattachmentexperiences,theirchild’sdistress),andteachingthemtousespecificemotion-coachingparentingskills(Gottmanetal.,1996).Thiscanoccurwithindividualparentsorwithcouples.Thetaskbeginswithsomebriefjoiningwork(e.g.,askingaboutparent’shobbies,job,etc.)wheretherapistsattempttohighlightparentalstrengthsandcompetencies.Fromthere,therapistsmoveintoasupportiveexplorationofstressorsaffectingtheparent(s)(e.g.,psychiatricdistress,maritalproblems,financialstressors,etc.)andhowthesestressorshaveaffectedparentingandfamilyrelationships.Thisphaseoftheconversationvalidatestheparentsexperiencesandreducesself-blameandguiltbyputtingparents’struggleswiththeiradolescentintoabroadercontext(e.g.,“Itishardenoughraisinganadolescent,letaloneadepressedone,whenyouhavealltheseotherstressorsinyourlife”).Next,therapistsexploreparent’sownexperienceofattachmentinchildhoodandhowtheseexperiencesmayhaveinfluencedtheirparentingandfamilyrelationships.Theseconversationsareoftenemotionalforparents,andtherapistsuseempathy,curiosity,andemotion-focusedtechniquesastheyexplorethishistorywithparents.Whenparentsexperienceempathyfortheirownattachmentvulnerabilitiesandneeds,theyoftengaininsightandperspectiveontheemotionalandpsychologicalneedsoftheirchild.Suchconversationscanrevivecaregivingmotivationinparents(e.g.,“IwanttobethekindofparentIwishedIhad”or“Iwanttobeformychildwhatmymotherwasforme”)andprovideamodelforapproachingsimilarlyemotionally-chargeddiscussionswiththeirteen.Inthissoftenedstate,parentsareoftenmoremotivatedhearwhatisontheteensmindandmorereceptivetolearningtheemotioncoachingparentingskillsthatarecriticalforsuccessintheRepairingAttachmentTask(Task4).Thetherapistthenfocuseson10E.S.K.Ewingetal.
teachingspecificskills(e.g.,helpingteenswithemotionrecognitionandlabeling,reflect-ingandvalidatingemotionsinconversationswithteens,andstrategiesforpromotingopendiscussionofemotions).Task4OncethegoalsofTasks2and3havebeenreasonablyreached,parentsandadolescentsarebroughttogetherforjointsessionsagaininTask4,theRepairingAttachmentTask.Task4typicallytakesplaceoveronetothreesessions.Thistaskculminatestheworkfromthepreviousthreetasksandprovidestheinvivocontextforexperientiallypracticingnewinterpersonalskills.Thesein-sessionconversationsfocusontheadolescentdisclosing,oftenforthefirsttime,pastandpresentexperiences,thoughts,andfeelingsthathaveviolatedtheattachmentbondanddamagedtrust.Thetherapistguidesandcoachesparentsandadolescentsthroughthisconversationbyremindingparentstouseemotion-coachingskillsandencouragingadolescentstobehonest,butregulated,intheirdisclosures.Whenattachmentepisodesaresuccessful,parentsrespondtotheiradolescent’spain,accusations,anger,andhurtinasupportive,understanding,andnon-defensivemanner.Insomecases,parentsevenapologizefortheirroleinpastattachmentfailures.Severalpurportedmechanismsofchangearethoughttobeactiveintheseconversa-tions.Fromacognitiveperspective,theadolescentbeginstoperceivetheirparentascaring,interested,abletotoleratetheirpainandanger,andabletooffersupportandvalidation.Thisexperiencechallengesandhelpsrestructureoldnegativeschemasofselfandotherandpromotesfeelingsofworthandentitlementtolove.Suchcognitiverestructuringshouldhelpbufferagainstdepression,worthlessness,andlowself-esteem.Fromtheperspectiveofemotionregulation,theseconversationsprovideexposureoppor-tunitiestomanagenegativeaffect,practiceemotionalexpression,andtolerateconflictordifferences.Adolescentslearntoarticulate,differentiate,andregulatetheiremotionsinthecontextofdiscussing“hotcognitions”andcorefamilyissues.Sustainedandsuccessfulexposuresintheseconversationsincreasetheirabilitytoregulateintenseemotions,andraisetheirexpectationsthattheirparentscantoleratethem.Finally,fromanattachmentperspective,thisencounterservesasacorrectiveattach-mentexperience.Adolescentsexperiencetheirparentsassensitiveandavailableforsupport.Thesesuccessfulconversationshelpadolescentsbegintoreviseinternalworkingmodelsoftheirparents(“Maybetheycanhelpme”)andofthemselves(“MaybeIamworthyofbeingcaredfor”).Overtime,andwithrepeatedpositivetherapeuticencounters,theadolescentdevelopsexpectationsthatparentscanbetrustworthyandsupportive.Astrustreemerges,adolescentsaremorelikelyturntotheirparentsforsupportandcomfort,ratherthanwithdraw,isolate,orhurtthemselves.Insum,Task4attachmentepisodesuseparent–childinteractionstocreateinvivoexperientialepisodesthataimtorestructureaspectsofintrapsychicfunctioning(cognitionsandaffectregulation)andinterpersonalfunctioning(parentcaregiving/teenattachmentbehavior).Theseintrapsychicandinterpersonalchangesostensiblyreinforceoneanotherinatransactionalmodelofchangewiththeultimategoalofestablishing/reestablishinggreaterattachmentsecurity.Task5Withtheestablishmentofgreaterrelationshipsecurity,thefamilycanthenreturntonegotiatingthemorenormativedevelopmentalchallengesofadolescence,andthetherapyAttachment&HumanDevelopment11
movesintoTask5,theAutonomyPromotingTask.Withoutattachmentsecurityintheparent–teenrelationship,adolescentsoftenunderminecollaborativeeffortswithparents,usingday-to-daybehavioralanddevelopmentalchallengesasopportunitiestoexpressunderlyingdiscontent.WithTask4completedandamoresecureattachmentbaseinplace,adolescentsandparentscanbeginmorenormativefunctioningwithina“goal-correctedpartnership,”apartnershipinwhichbothteenandparentareabletocommunicateeffectivelyandarewillingtonegotiateandcompromiseinordertomaintainamutuallygratifyingandsupportivebond(Allen,2008;Kobak&Duemmler,1994).Task5typicallytakesplaceoverfourtoeightsessions.WhileTask4conversationsfocusspecificallyonnegotiatingtrust,love,andsecurity,Task5conversationsfocusonpromotingtheadolescent’scompetenceandautonomyinotherareas,usingparentsforsupportandguidance.Task5sessionsfrequentlyincludediscussionsaboutotherinflu-encesontheadolescent’sdepressivesymptoms(e.g.,peers,school),negotiationofhouse-holdrules(e.g.,curfew,chores),andengagementinactivitiesandinterests.Manydepressedadolescentshavewithdrawnfromsocialandpeeractivitiesandneedhelpreengaging.Withrelationalrupturesonthemend,parentsarebetterpositionedtohelpadolescentswiththesechallenges.Thetherapistaimstoelevatetheseconversationstofocusoncommunicationandnegotiationsratherthanbehavioralmanagement.Theoldertheadolescent,themoretheyareencouragedtomakesignificantcontributionstothehomeandtotakeresponsibilityfortheirownlifegoals.Therapistsseethesediscussionsasopportunitiesforadolescentsandparentstopracticenewmorerespectfulandregulatedinterpersonalproblem-solvingstrategies.Problem-solvingtraininghasbeenavaluablecomponentinothertreatmentmodal-ities,butisrarelydoneinafamilycontextwherecollaborativelyresolvingproblemscanalsobeattachmentbuilding.Furthermore,successfulproblemsolvingandsuccessinschool,peerrelationships,etc.,buildsasenseofcompetencyandincreasespositiveexperiences,whichcanfurtherbufferagainsthopelessness,depression,andsuicidalideation(Cole,1990;Dumont&Provost,1999).Inmanycases,teensandparentsarealsoabletomoveintodeeperdiscussionssurroundingadolescentidentitydevelopment(e.g.,ethnicity,sexuality,spirituality),emergingadulthood,andparentandteenhopesanddreamsforthefuture(i.e.,whatkindoflifedoeseachofthemenvision).WhiletheRepairingAttachmentTasksolidifiesrelationshiptrustandsecurity,thePromotingAutonomyTasktestsandreteststhesenewfounddynamics,consolidatinggainsandexpandingcontexts.TheABFTtherapistABFTisrootedinfourdifferentclinicaltraditions:(1)StructuralFamilyTherapy(Minuchin,1974);(2)MultidimensionalFamilyTherapy(Liddle,2002);(3)EmotionFocusedTherapy(Greenberg,2002;Johnson,2004);and(4)ContextualFamilyTherapy(Böszörményi-Nagy&Spark,1973).SFTandMDFTstronglyinfluencetheABFTtherapist’sattentiontofamilyprocessesduringsessions(e.g.,Whotendstospeakup/shutdowninfamilyconversations?Howdoroleschangeorstaythesameduringconflict/crises?).CFT,togetherwithattachmenttheory,helptoinfluencethecontentfocusoftherapy(e.g.,experiencesinrelationshipswithotherfamilymembers,relationalinjuries,trust,andloss).EFTtechniquesguidethetherapistinamplifyingandexploringtheemotions(oftenavoided)thatareassociatedwiththiscontent.(AfulldiscussionofABFT’sclinicalrootsisincludedintheABFTtreatmentmanual;Diamondetal.,2013.)12E.S.K.Ewingetal.
Withfoundationsinmultipletheoreticaltraditions,fivetreatmenttasks,andacombinedindividualanddyadicapproach,ABFTisahighlyintegrativeapproachtotherapy,combin-ingtheoryandtechnique.Thisapproachrequiresclinicianstobecomfortableusingavarietyoftherapeuticstrategies.Tobegin,therapistsmustbecomfortablewithbasictechniquesthatareintegralforallianceandtrustbuildinginindividualworkwithadoles-centsandparents(e.g.,empathy,respect,emotionalresonance).AsABFTisadirectivetherapy,therapistsmustalsobecomfortablebeingdirectwithpatientsandkeepingthemfocusedonthegoalsofeachtask,whilemaintainingtherapeuticalliance.Inaddition,therapistsmusthavesomeskillwithemotion-focusedtechniques,whichareessentialforthepreparatoryworkinTasks1,2and3.Thesetechniques,includingemotionidentifica-tion,elaboration,intensification,anddifferentiationofprimaryandsecondaryemotionshelptherapiststoguideadolescentsinidentifyingandexperiencingfearedandavoidedemotions,deepentheseemotions,andsustaindifficultconversations–allstrategieswhichcanhelpthetherapistandadolescenttouncovercoreattachmentinjuries.TheABFTtherapistmustalsobecomefamiliarwithattachmentclassifications/styles(e.g.,securevs.dismissingvs.preoccupiedstyles).Understandingofattachmentclassi-ficationshelpstherapiststoconceptualizeattachmentinjuriesandhowtosupporttheteenandtheparentinresolvingtheseinjuries.Forexample,thetherapistmayhypothesizethatateenhasadismissiveattachmentstylemarkedbywithdrawalandindifference.Understandingthatdismissiveattachmentisoftenassociatedwithexperiencesofrejectionandcaregiver’slackofemotionalavailabilitycanbehelpfulincaseconceptualizationandchoiceofin-sessioninterventions(e.g.,typesofquestionsandprobing,identificationofattachmentinjuries,emotion-focusedtechniques).Finally,forconjointparent–teensessions,itisessentialthattheABFTtherapisthavecomfortwithinitiatingandorchestratinginvivoconversations,orenactments,betweenfamilymembers(e.g.,“Mom,turntoyourdaughterandaskherhowshefeelswhenyoucriticizeher”).Therapistsmustbeabletobalancetheneedtoremainminimallyinvolvedintheseconversations(i.e.,letfamilymembersinteractmostlywitheachother),withtheequallyimportantneedtomonitorandcoachfamilymemberstomakesuretheconversa-tionissafe,productive,andsustained.Duringenactments,therapistsmustserveascoachandguide,helpingtodirectconversationwhenfamilymembersgetstuck,pointingoutandblockingnegativeprocesses(criticism,defensiveness),whileallowingtheconversa-tiontobebetweenfamilymembersasmuchaspossible.UseofABFTtechniquesandtherapistadherencetothetreatmentgoalsisimportant.Processstudieshaveshownassociationsbetweentherapistadherencetotreatmentgoalsandoutcomes.Forexample,attachment-orientedstrategiesandstatements(e.g.,relationalreframestatements,identifyingcorerelationalthemes,highlightingvulnerableemotions)wererelatedtoparentalshiftstoamoreinterpersonalviewoftheirteensdepression(Moran,Diamond,&Diamond,2005).Anotherprocessstudyshowedthattherapists“useofrelationship-facilitatingstrategiesandstatements,suchasempathyandpositiveregardforparents,wereassociatedwithparents”nonnegativeattitudestowardtheiradolescentinsubsequentsessions(Moran&Diamond,2008).Ongoingprocessstudiesareexaminingrelationshipsbetweentherapeuticalliance,agreementontreatmentgoals,decreasesinparent–adolescentconflict,adolescent’sself-rateddepressionandparentratingsofimprovementoverthecourseoftreatment.Insum,whilefurtherresearchisneeded,findingsthusfarhavesuggestedthattherapistadherenceandproficiencywithABFTtechniques(alliancebuilding,directed-ness,attachmentinjuryidentification,emotion-focusedstrategies)relatetoavarietyofpositiveABFTtreatmentoutcomes.Thisincludesprimaryoutcomes,suchasdecreasesinAttachment&HumanDevelopment13
reporteddepressionsymptoms,aswellaschangesinpotentialtreatmentmechanisms,suchasdecreaseinfamilyconflict,negativeparenting,andadolescentattachmentrelatedanxietyandavoidance.Task-specificABFTadherencemeasurescanaidetherapistsindevelopingABFT-relatedtreatmentskillsandstrategies.Thesemeasuresoperationalizethemanual’spre-scribedinterventionstrategiesandtechniques.Adherencedependsonthecumulativeabilityofatherapisttodeliverspecificelementsofthetask.Theratingscalesprovidetherapistsandsupervisorswithspecificanddetaileddescriptionsofexpectationsandgoals.Thesemeasuresarebeingcontinuallytestedandrefinedtoserveasatrainingaidinthedevelopmentoftherapists’ABFTskills.ThetrainingandcertificationprocessforABFTtypicallyoccursoveratwoyearperiodandrequiresseveralsteps.Initially,therapistsarerequiredtoreadtheABFTtreatmentmanual(Diamondetal.,2013)andthenattendathreedayworkshop.TheworkshopincludesacompleteoverviewofthetheoreticalprinciplesandclinicalstrategiesofABFT,videoreview,androle-play.TherapistsarealsotaughthowtousetheABFTadherencechecklists.Aftertheinitialworkshop,traineesparticipateingroupcasecon-sultation(byphoneorInternet),everyotherweekfor90minutes.Sixmonthslater,anon-sitethreedayadvancedtrainingisheldthatincludestapereviewandlivesupervision.Aftertheadvancedworkshop,traineesbegintosubmitvideorecordingsoftheirwork.ABFTsupervisorsreviewtheserecordingsandprovidewrittenandverbalfeedback,includingadherenceratings.InordertobecertifiedasanABFTtherapist,traineesmustreceiveanaveragescoreof“4”orbetterontapesrepresentingeachABFTtask.Certificationlastsforfouryears.EmpiricalsupportforABFTTodate,fourstudieshavebeenconductedthatdemonstratetheefficacyofABFT.Allstudieshavefocusedonadolescentswithdepressionand/orsuicideriskandhaveusedtheseproblemsasthemeasuredoutcomes.Specifichigh-riskpopulationshavealsobeenexaminedaspartofthesestudies,includingsexualminorityyouth(gay/lesbian/bisexual)andyouthwithahistoryofsexualabuse(Diamond,Creed,etal.,2012).EmpiricalsupporttodatejustifiesABFTasmeetingthecriteriaofapromisingintervention(Chambless&Hollon,1998).StudyIIna2002studybyDiamondetal.,clinicallydepressedadolescents(ages13–17)wererandomizedto12weeksofABFTorsixweeksofawait-listcontrolcondition.Atpost-treatment,patientstreatedwithABFTweremorelikelytonotbeexperiencingclinicallysignificantsymptomsandweremorelikelytonolongermeetcriteriaforMajorDepressiveDisorder(MDD),comparedwithwaitlistedpatients.StudyIIIna2010studybyDiamondetal.,adolescentpatientswererandomizedto12weeksofABFTorenhancedusualcare(EUC,facilitatingreferralstocommunitytreatment).Assessmentoccurredatbaseline,sixweeks,12weeks,and24weeks(follow-up).Comparedtousualcareinthecommunity,youthtreatedwithABFTdemonstratedsignificantlygreaterreductionsinsuicidalideationduringtreatmentandsignificant14E.S.K.Ewingetal.
differencespersistedatfollow-up,withanoveralllargeeffectsize(d=.97.)Thisisoneofthefewstudiestodemonstratethataresearchtreatmentwasmoreeffectivethantreatmentasusualforreducingsuicidalideationinadolescents(Tarrieretal.,2008).Efficacywasalsodemonstratedwiththemostsevereyouth,includingthosewhopresentedwithcomorbidanxiety,severesuicideideation,ahistoryofsexualabuseandahistoryofmultiplesuicideattempts.ResultsalsoindicatedthatABFTwasassociatedwithgreaterratesofclinicalrecoveryandclinicalrecoverybenefitsweremaintainedatfollow-up.ABFTpatientsalsoexperiencedmorerapidrelieffromdepressionthancommunitycare,acriticalconsiderationfordepressedadolescentsandtheirparents.Finally,retentionwasbetterintheABFTgroup,evenwiththeadditionalsupportsofferedintheEUCmodel(e.g.,frequentcheck-incallsandresourcecoordination)(Diamondetal.,2010).Indeed,retentionwasbetterthanseveralresearchstudiesthathavedesignedtreatmentsspecifi-callytoenhanceengagementandretention(Rotheram-Borusetal.,1996;Spirito,Boergers,Donaldson,Bishop,&Lewander,2002).StudyIIIIna2012studybyIsraelandDiamond,adolescentsmeetingcriteriaforMDDinthreeoutpatientcommunityclinicsinsouth-westNorwaywererandomizedtoABFTortreat-mentasusual(TAU).PatientstreatedwithABFThadsignificantlylowerratingsontheHamiltonDepressionRatingScaleandhigherratesofrecoverythanpatientsinTAU.AdolescentsinABFThadsignificantlybettersymptomreductionthanadolescentsinTAUonclinicianratings.ThispilotprojectwasthefirsteffectivenessstudyonABFTandshowedpreliminaryfeasibilityoftrainingcommunity-basedtherapistsandimprovingcommunity-basedcare.StudyIVIna2012open-trialpilotstudy,ABFTwasadaptedtomeettheuniqueneedsofsuicidal,openlyLGByouthandtheirparents(Diamond,Diamond,etal.,2012).TensuicidalandopenlyLGByouthandtheirfamiliesreceived12weeksofLGBsensitiveABFT.Acrossthesample,suicidalideationanddepressivesymptomssignificantlydecreased,asdidanxietyandavoidanceinrelationshipswithmothers.Thesefindingssuggestthatfamily-basedtreatmentsthatfocusonrelationalthemesmaybepromisingforsuicidalopenlygayyouth(Diamond,Diamond,etal.,2012).ConclusionandfuturedirectionsABFTwasdesignedasafamily-basedtreatmentaimedatstrengtheningparent–teenrelationshipstohelpbufferagainstadolescentdepressionandsuiciderisk.Asaresultof15yearsoftreatmentdevelopmentandempiricalresearch,ABFTisemergingasapromisingevidence-basedandempiricallysupportedtreatmentforteenswhostrugglewiththesedisorders(http://nrepp.samhsa.gov).However,manyimportantquestionsremaintobeanswered.First,willtheefficacyofABFTholdupwhentestedagainstamorerigorouscontrolcondition,asopposedto“treatmentasusual”(thecomparisonconditioninthefirstRCT)?AsecondquestioniswhetherABFT-relatedreductionsindepressionaremaintainedandpersistatfollow-uppoints(e.g.,sixmonthsoroneyearaftertreatment).Additionally,thepurportedmechanismsofABFT-relatedchange,andtheirimpactontreatmentoutcome,haveyettobetested(changesinadolescentAttachment&HumanDevelopment15
attachment;improvedemotionregulation;improvedinterpersonalskillsandconflictresolutionabilities).Currently,manyofthesequestionsarebeingaddressedinafive-yearNIMHrando-mizedcontrolledclinicaltrial.Inthisstudy,adolescentsarerandomizedtoeither16weeksofABFTorFamilyEnhanced-Non-directiveSupportiveTherapy(FE-NST;Brent&Kolko,1991).Unliketreatmentasusual,thecontrolgroupinthisstudywillallowforcontroloftreatmentdose,duration,familyinvolvementandfidelitytoadefinedtreatment.Across-overdesignisbeingusedwithstudytherapists(i.e.,thesametherapistsareusedtodeliverbothtreatments.Thus,therapisteffectswillalsobecontrolled.Thestudyalsoincludesoneyearfollow-updatatoexaminemaintenanceoftreatmentgains.OneofthemostinnovativeaspectsofthestudyistheuseoftheAdultAttachmentInterview(Georgeetal.,1996)andapre-postfamilyinteractiontask.DatafromtheAAIwillbeusedtotestchangesinadolescentattachment,whiledatafromtheinteractiontaskwillbeusedtomeasurechangesintheparent–teencommunicationaroundsourcesofconflict,aproxyforchangesinthegoal-correctedpartnership.Ifsuccessful,thefindingswillprovideevidenceforboththeefficacyandspecificityofABFTtreatmentmechanisms.Todate,ABFThasbeenstudiedintightly-controlledefficacystudieswithhighlytrainedandsupervisedtherapists.ItwillalsobeimportanttoconductstudiesexaminingtheeffectivenessofABFTincommunity-basedfacilitiesandit’stransportabilitytonon-academicsettings.Futurestudiesneedtoexamineifandhowcliniciansinnon-academicsettingscanbetrainedtoeffectivelyutilizetheABFTtreatmentprotocolwithdepressedandsuicidalteensandtheirfamilies.WhiletheABFTtrainingandcertificationprogramhasreportedlyhadgoodsuccesstrainingsuchclinicians,effectivenessstudiesareneededtoempiricallyvalidatethesereports.Finally,iftheefficacyandeffectivenessofABFTcontinuetobesupported,itwillbeimportanttounderstandwhethertheuseofmoreintensivefamily-basedtreatmentslikeABFTcanimproveoutcomesandcareforsuicidalteensinclinicalsettingsotherthanoutpatientpsychotherapysettings.Forexample,couldABFTbeusedininpatientpsychiatricunitstoreducetheriskofsuicideattempt/reattemptorthedurationofhospitalization?Ontheotherendofthespectrum,couldABFTusedincommunity-basedprimarycaresettingstoreduceratesofhospitalizationanddecreasedepressionandsuiciderisk?Despitethemanyquestionsthatremain,thecurrentevidencesupportsABFTasapromisingfamily-basedinterventionwithdemonstratedefficacyforreducingadolescentdepressionandsuiciderisk.Additionalempiricalevidence,alongwithfindingsfromongoingstudiesaboutpotentialmechanismsofchange,willhelpresearchersandclin-iciansdevelopabetterandmorecompleteunderstandingregardingtherelationalnatureofsuicide,thefeelingsofisolation,helplessnessandhopelessnessthatoftendriveit,andthebestwaystoeffectpositivechange.ReferencesAdam,K.S.,Sheldon-Keller,A.,&West,M.(1996).Attachmentorganizationandhistoryofsuicidalbehaviorinclinicaladolescents.JournalofConsultingandClinicalPsychology,64(2),264–272.doi:10.1037/0022-006X.64.2.264Ainsworth,M.D.S.(1982).Attachment:Retrospectandprospect.InC.M.Parkes&J.Stevenson-Hinde(Eds.),Theplaceofattachmentinhumanbehavior(pp.3–30).NewYork,NY:BasicBooks.Allen,J.P.(2008).Theattachmentsysteminadolescence.InJ.Cassidy&P.R.Shaver(Eds.),Handbookofattachment:Theory,research,andclinicalapplications(2nded.,pp.419–425).NewYork,NY:GuilfordPress.16E.S.K.Ewingetal.
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