Attachment-Based Family Therapy
Name of Model
Attachment-Based Family Therapy
Attachment-based family therapy (ABFT; Diamond et al. 2014) is a trust-based, emotion-focused, empirically supported treatment that aims to repair interpersonal ruptures and rebuild secure, protective caregiver-child relationships. ABFT is designed to improve the family’s capacity for affect regulation, relational organization, and problem solving. This strengthens family cohesion, which can buffer against depression, suicidal thinking, and risk behaviors (Restifo and Bogels 2009). This framework is particularly relevant to adolescents for whom the family context is inescapable (Maccoby and Martin 1983). ABFT is rooted in structural family therapy, multidimensional family therapy, emotionally focused therapy, and contextual family therapy. The ABFT manual is interpersonal and process-focused, but offers a structure and roadmap for how to facilitate depth-oriented therapy in a 12 to 16 week period. The model unfolds in five distinct, but interrelated, treatment tasks that focus on critical treatment processes. These tasks serve as a guide for helping the family to repair attachment ruptures and work toward increasing trust and security.
Prominent Associated Figures
Guy Diamond, Ph.D.
Gary Diamond, Ph.D.
Suzanne Levy, Ph.D.
ABFT is a brief family-based therapy with a solid grounding in attachment theory (Bowlby 1969). This theory proposes that when children are distressed, they are “hard-wired” to seek support and comfort from their parents. When children experience their parents as responsive and available in the face of distress, they begin to feel that (a) the world is a safe place and (b) they are worthy of being loved protected. Over time, these experiences of protection become internalized as working models (or expectations) of relationships. If a child is treated well, then they seek out similar relationships. When a child is treated poorly, they internalize expectations that their relationships will be unresponsive, if not hurtful. In the face of these untrustworthy relationships, children develop attachment (interpersonal) strategies that will protect them from more harm: dismissive, preoccupied, or disorganized.
If internal working models are shaped by real relationships, then these real relationships can revise internal working models and other behavioral changes. ABFT aims to revive the adolescent’s hope for attachment security and promote responsive parenting. Improving the family’s communication, problem-solving, and emotional regulation can create the corrective attachment experiences that help adolescents work through past traumas and relational ruptures. This establishes the groundwork for rebuilding secure relationships with parents.
Strategies and Techniques Used in ABFT
In ABFT, the “corrective attachment experience,” and subsequent autonomy building, is engineered using five distinct treatment tasks. Tasks are not equated with sessions. Instead, a task is a set of procedures, processes, and goals related to resolving or accomplishing specific aims in therapy (e.g., building alliance). Task I offers a roadmap for establishing an essential and common process inherent to many family therapy models: getting the family members to agree to work on relationship building rather than behavioral management. To achieve this, the therapist focuses on resuscitating the adolescent’s desire for protection and support as well as the caregivers’ longing for love and connection with their child. The therapist promotes the caregivers as “the medicine” to help the adolescent cope with, and recover from, depression and suicidal ideation.
Task II consists of individual sessions with the adolescent. The therapist aims to help adolescents identify and articulate their perceived experiences of caregivers’ attachment failures and prepare them to discuss these felt injustices in Task IV. Task III consists of individual sessions with the caregivers. The therapist aims to help each caregiver consider how their own life stressors and intergenerational legacies of attachment ruptures affect their parenting style. This insight helps caregivers develop greater empathy for their adolescent’s experiences. With this insight, caregivers become more motivated to learn new emotion coaching and parenting skills.
Targeted risk factors, relevant treatment task, and expected outcomes. Adapted from Diamond et al. (2003)
Caregiver criticism and blame
Caregivers and adolescent become more willing to focus on relationship building instead of behavior management
Adolescent hopelessness about, and disengagement from, caregiver
Alliance building with adolescent
Build treatment bond with adolescent, help them understand their attachment rupture narrative, and prepare them to discuss these stories with their caregivers in task IV
Caregiver stress and abdication
Alliance building with caregivers
Build treatment bonds with caregivers, increase caregiver awareness of adolescent’s attachment needs, and teach parenting skills that will promote attachment-repairing conversations in task IV
Adolescent-caregiver disengagement and conflict
Increase adolescent’s perceptions of caregivers’ availability and protection, increase adolescent’s confidence in communicating his or her needs, build caregivers’ view of their adolescent as having legitimate concerns (who can express themselves in a direct and emotionally regulated manner), work through memories of loss and abuse, and improve interpersonal and conflict resolution skills
Poor adolescent functioning in extra-familial contexts
Promote caregiver support for adolescent competency and autonomy
Increase adolescent’s use of the caregivers as a secure base for problem solving and identity development
Populations in Focus
ABFT is a therapy for adolescent depression and suicide; however, youth with other presenting problems can benefit from the clinical model. ABFT has been useful for clients with histories of trauma, eating disorders, substance use, or victimization due to their sexual identity (see full review in Diamond et al. 2016a). ABFT is flexible enough to incorporate comorbid conditions and has gained empirical support for young adults with unresolved anger toward a caregiver (Diamond et al. 2016b).
Low income, minority families have been absent from many of the clinical trials testing psychotherapies for youth depression and suicide (Bernal et al. 2009). ABFT, however, has had a history of success working with diverse families. In general, ABFT is recommended for clients 12 years of age and older and is not limited by treatment context. The model has been used in outpatient, inpatient, home-based, hospital settings, and residential care. ABFT is not recommended as a treatment approach for clients with active psychosis, low-functioning autism spectrum disorders, borderline intellectual functioning, or severe externalizing behaviors. However, the guiding principles and tasks of ABFT can be applied when working with any family.
ABFT research is conducted at the Center for Family Intervention Science (CFIS) at Drexel University and at partnering sites throughout the world (Diamond et al. 2016a). ABFT research has focused primarily on reducing depression and suicide in adolescents, ages 12 to 18. To date, several studies have been conducted demonstrating the efficacy of ABFT. These studies have shown that ABFT is more effective than waitlist control groups or treatment as usual in reducing depression and suicidal ideation. ABFT has also been adapted for use with suicidal LGB adolescents (Diamond et al. 2012). Secondary data analysis indicates that ABFT is effective for severely depressed adolescents and those with a history of sexual abuse, both predictors of poor response in treatment with combined medication and cognitive behavioral therapy (Asarnow et al. 2009; Barbe et al. 2004). Also several process studies have explored the proposed mechanisms of change (see Diamond et al. 2016a for a review). A new study comparing ABFT to Family-Enhanced Non-Directive Supportive Therapy has just been completed. Results are not yet available, but seem very promising.
Several effectiveness research projects have been conducted or are currently underway. Israel and Diamond (2013) explored the feasibility of training therapists to conduct ABFT in a hospital setting in Norway. Similar implementation challenges are explored in three recent papers on implementing ABFT in Australia (Diamond et al. 2016c), Belgium (Santens et al. 2016), and Sweden (Ringborg 2016). In the United States, we have recently partnered with an LGBTQI youth center to conduct an implementation study of ABFT in a community counseling center working with this population. This empirical support reviewed above meets the criteria for a promising intervention (Chambless and Hollon 1998) and ABFT is currently listed on the National Registry of Evidence-based Programs and Practices (NREPP).
Brittney was a 17 year old, African American, and Caucasian (biracial) adolescent who lived with her mother, Sharise, and younger brother. The father lived in the home until Brittney was nine; however, he was not involved in her life at the time of this therapy. The family was referred from a local inpatient psychiatric hospital after treatment for severe suicidal ideation. Brittney struggled throughout her life socially and academically. Although very creative, athletic, and intelligent, Brittney reported difficulties “fitting in” and being bullied given her biracial identity. She discussed how she felt “not black enough.” These issues with peers impacted her ability to attend school.
Sharise self-identified as African American and came to therapy with concerns about her daughter’s suicidal ideation, depression, anger, and “out of control” sexual behavior. Specifically, Sharise had recently “caught” her daughter kissing “an older guy” outside of her school. Sharise described her daughter as being highly susceptible to peer influence (e.g., cutting class to hang out with friends, provoking fistfights in school, and staying out past curfew). Sharise reported no history of family mental health concerns, but described a history of domestic violence in several of her past romantic relationships and between her own parents in childhood. At the time of treatment, Sharise had a steady job and was single.
Brittney and Sharise attended ABFT sessions for 4 months. Sessions were focused on repairing ruptures between mother and daughter. The primary ruptures involved Brittney’s feelings of “being attacked” by her mom when she tried to share feelings about being bullied at school, feeling rejected by her father, and feeling abandoned by her mom during episodes of domestic violence between Sharise and her previous partners. After trust was rebuilt between mother and daughter, sessions focused on being bullied, school struggles, career goals, identity development (e.g., what it means to be a biracial woman), and sexuality.
Task I: Relational Reframe. Initially the therapist joined with Sharise around her concerns about her daughter’s depression, sexual behavior, and peer relationships. She also joined with Brittney around her depression which resulted from being bullied, feeling rejected by her father, and feeling as though she did not “fit in” given her biracial identity. The primary focus of the Relational Reframe was captured in the following question: “When you feel so bad that you want to hurt yourself, why don’t you go to your mother for help?” In response, Brittney disclosed that she worries about her mom’s negative opinions of her and does not want to stress and burden her mother. Brittney expressed that, in the past, she had felt more comfortable talking to her few close friends and boyfriend; however, with her recent struggles with peers, she felt completely “alone.” At first, Sharise was frustrated with Brittney for not coming to her. The therapist shifted Sharise’s tone by acknowledging her love and concern for Brittney and asking her to share those emotions: “Let your daughter know how sad you are that she does not trust you. Let her know how worried you are that she is all alone.”
This softened the mood in the room and shifted the family from anger to sadness. At this point, Brittney and Sharise could focus on interpersonal ruptures instead of problem behavior. Both mother and daughter were able to remember the close relationship they once shared and how distant they had become. The therapist helped them acknowledge that they felt this loss of closeness. With the relational narrative now at the center of the conversation, Sharise agreed to the relational treatment contract: to make relationship repair the initial goal of the treatment. Brittney was more hesitant. She, like many adolescents, had lost hope that family relationships could improve. Brittney was protecting herself from further hurt by no longer wanting attachment security. The therapist validated this concern but also talked about the consequence of being so alone in life: depression and suicide. After the therapist explored her resistance and validated her concerns, Brittney agreed to come to the next session and discuss this further with the therapist alone.
Task II: Adolescent Alliance. The therapist met with Brittney for her first Task II session to continue building an alliance and to better understand her depression and suicidal ideation. After this initial session, Brittney participated in two more Task II sessions where she discussed what got in the way of going to her mother for help and support (e.g., relational ruptures). Brittney noted two ruptures that were different from those originally identified in Task I. First, rather than being worried about her mother’s opinion of her or feeling like a burden, Brittney actually felt attacked and humiliated by her mother. Specifically, she said that when she shared things with her mother, the mother would then follow her around the house and “yell” at her if she did not keep talking about these things. If she brought up feelings about her father, her mother would “lash-out” and reprimand her for wanting a relationship with such a “horrible man.”
Brittney also described feeling abandoned by her mother during the scariest moments in her life. Brittney had witnessed episodes of domestic violence that her mother suffered at the hands of multiple romantic partners. This had never been discussed before. In sessions, Brittney talked about the impact that witnessing the violence had on her as well as the consequences of not being able to talk with her mother about these events. These conversations helped Brittney understand how these relational ruptures impacted her sense of safety and security in her relationship with her mother (i.e., her attachment rupture narrative). The therapist spent the fourth session of Task II helping Brittney see the link between her attachment narrative and her depression and suicidal ideation. Understanding this link motivated Brittney to talk to her mom about the ruptures. The therapist then spent time preparing Brittney for these conversations.
Task III: Caregiver Alliance. In this task, Sharise was initially very guarded and worried about being judged or blamed for her daughter’s problems. In the first session of Task III, the therapist got to know Sharise better, including her work responsibilities, social life, supportive relationships, and current stressors. Sharise was burdened with balancing childcare and her job. She described feeling “stressed,” “exhausted,” and “guilty” on a daily basis. Sharise acknowledged that these stressors impacted her capacity to be present with her children. The therapist also helped her realize that when she felt worried about her daughter (e.g., when Brittney failed to arrive home on time), this would trigger her own feelings of guilt. Sharise actually attributed her daughter’s acting out behavior as a result of her own lack of availability as a mom. When these feelings of guilt were triggered, Sharise tended to lash out verbally at her daughter. Despite this initial work to understand how current stressors impacted her, Sharise remained highly defensive. In the next Task III sessions (sessions two and three), the therapist explored Sharise’s intergenerational history, specifically helping her talk about vulnerable moments as a child. At first, Sharice resisted exploring her own history of attachment ruptures. The therapist worked slowly with Sharise to uncover fears and disappointments resulting from witnessing domestic violence in her own family of origin. The therapist used information gathered in Task II with Brittney to look for similar attachment themes in mom’s life. Sharise struggled to emotionally connect to her own childhood experiences of betrayal and abandonment.
In the therapy, Sharise would often distance herself from the emotional intensity of the conversation by flippantly saying, “Oh I just had to get over all this.” Each time Sharise retreated like this, the therapist would gently invite her back into uncovering more vulnerable feelings. To stay in this zone, Sharise’s primary emotions related to abandonment and neglect needed to be identified and validated. Only when Sharise could allow herself access to these more vulnerable feelings could she begin to have more empathy, rather than indifference, for her own painful experiences as a child.
Once she was able to acknowledge this, the therapist helped her empathize with her daughter’s experience of witnessing domestic violence and having no one to turn to for support. Sharise quickly realized what her daughter needed to resolve these frightening experiences.
Brittney needed to have someone help her understand these frightening events and tell her it was not her fault; just what Sharise wished she had gotten from her mother.
The therapist spent the fourth session of Task III helping Sharise identify how themes of abandonment permeated her own life and her current approach to parenting. Sharise acknowledged that she was “walking with blinders on.” She admitted that she wanted to deny that the witnessing of domestic violence had an effect on her daughter. She also acknowledged that she attacked her daughter out of guilt. Specifically, when her daughter unknowingly reminded Sharise of her own “failings” as a caregiver, she felt accused and blamed. Sharise now recognized how her daughter must have felt during their times of conflict; Sharise said “I didn’t know how to manage my own hurt when Brittney needed me.” In this task, Sharise developed a new narrative about herself, her childhood, and her parenting – an approach that had more tolerance for painful feelings. In the fifth and final Task III session, the therapist offered Sharise the opportunity to change her relationship with her daughter. Once Sharise agreed, the therapist prepared her for the first Task IV conversation.
Task IV: Repairing Attachment. Building on the preparation in Task II and Task III sessions, Brittney and Sharise immediately engaged in an attuned discussion about relational ruptures in Task IV. In the first session of Task IV, they discussed how Brittney felt alienated and attacked by her mother when she tried to talk to her about upsetting experiences. After some discussion of this, Brittney shared her feelings of being rejected by her father and how bad this made her feel about herself. With the help of the therapist, Sharise listened to her daughter’s feelings with empathy, rather than criticism and interrogation. In fact, Sharise was so moved by Brittney’s sadness that she physically moved closer and comforted her daughter as she cried. In this moment, the therapist had the adolescent sharing vulnerable feelings and the parent providing comfort and protection: a corrective attachment experience. This conversation also laid the foundation for the more difficult discussions about domestic violence.
In the second Task IV session, they talked about Brittney’s experience of fear and abandonment during the episodes of domestic violence. With the support of the therapist, Brittney disclosed feeling abandoned by her mother because she had never asked Brittney about these events. After mom validated, rather than dismissed, Brittney’s feelings, Brittney began to share her memories of the violence. In this conversation, the therapist encouraged Sharice to listen, be curious, ask questions, and not talk too much. The therapist also discouraged her from apologizing too quickly, as this often brings closure to a conversation that the therapist wanted to sustain. When the time was right and Brittney had shared her full story, Sharise gave her daughter an honest apology for not being there for her during those difficult times. Sharise also shared a bit about her own life experiences as a child, but not so much that the mom would become the center of attention.
In Task IV sessions, the conversations between Brittney and Sharise were different from those in the past. Mom was softer and Brittney was more willing to share her experiences and emotions openly. At the end of Task IV, the therapist asked the family to reflect a bit on how these conversations had gone. Mom and daughter both acknowledged how different the other one had been: both more open, more receptive, and more honest. They both realized how often they bury their hurt feelings and how much better it was to share them with each other. Mom and daughter only needed two Task IV sessions before moving on to Task V.
Task V: Promoting Autonomy. Sharise and Brittney had four Task V sessions to discuss issues contributing to Brittney’s depression (e.g., being bullied, struggling to fit in, school attendance), plans for the future (e.g., work, college), and personal development (e.g., sexuality, romantic relationships, biracial identity). All of these conversations allowed Sharise to practice supporting her daughter on her path toward womanhood. The therapist encouraged Sharise to serve as a support for her daughter (i.e., help Brittney express her emotions and make better decisions). By the end of Task V, the family felt like trust was coming back, reducing mom’s worries about her daughter’s “out of control” behaviors and increasing Brittney’s tendency to go to mom for support.
Case Review. At the close of the final session, both mom and daughter felt able to continue having conversations together about future difficulties. Brittney began college preparatory courses with her mom’s support and actively visited local community colleges to learn more about business programs. By the end of therapy, Brittney had begun thinking about the possibility of starting a hair styling and braiding service. Suicide was no longer a needed coping strategy, and the family had a plan in place if suicidal thoughts returned. Specifically, Brittney felt like she could go to her mom for care and support. Brittney’s depressive symptoms and suicidal ideations had dropped to a nonclinical level. Brittney and Sharise found ABFT to be successful in helping them regain their closeness. Although not all cases go this smoothly, many families successfully progress through the five tasks in 12 to 16 weeks. ABFT can accomplish this rapid progress because the model focuses directly on the issues that lie at the heart of the matter for families: love, commitment, and trust.
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