A Q&A with Two of the Founders of Attachment-Based Family Therapy: Repairing the Parent-Child Relationship

Attachment-Based Family Therapy (ABFT) is a trust-based and emotion-focused psychotherapy model developed by Guy Diamond, Suzanne Levy, and Gary Diamond. Through a series of five treatment tasks with distinct goals and strategies, ABFT is designed to address adolescent suicide and depression by repairing and strengthening caregiver-child relationships.

Since early 2018, Newport Academy has been in the process of adopting the ABFT framework as our foundational clinical model. Suzanne and Guy have been working with Newport Academy leadership to train all clinical staff in ABFT methodology and practice.

In this Q&A, Suzanne and Guy share more about the process, its origins, and how it rebuilds the parent-child relationship.

The Underpinnings of ABFT

Are there varied types of family therapy?

Guy: Many family therapy models emerged out of working with youth with externalizing problems, such as delinquency, substance use, and ADHD. The main goal at that time was to help parents provide more structure and leadership in the family in order to manage the kids’ out-of-control behaviors. The idea was that, regardless of the diagnostic problem (e.g., substance use or depression), parents needed to provide structure and organization for the family. That’s good work and can be helpful.

What inspired the creation of ABFT?

Guy: ABFT emerged out of working with kids with histories of trauma, depression, suicide, and anxiety. We found that it wasn’t about the family needing more structure, limits, and rules. The family needed more warmth, more affection, and a stronger sense of safety. That led us to turn to attachment theory as a framework for thinking about parents’ instinctual desire to protect their children, and children’s instinctual desire to turn to their parents for love and protection.

That inspired us to formulate a different kind of family therapy that was about figuring out what was getting in the way of children turning to their parents for help when they felt depressed and/or suicidal. Why weren’t they going to their parents for protection, safety, and soothing? ABFT focuses on working on the things that have gotten in the way of trust, so children can turn to their parents for help.

Adolescence is naturally a time of renegotiating one’s attachment and connection. The healthiest teens stay connected while also developing autonomy and independence; we now understand that this is the central developmental task of adolescence. For kids who have mental health problems, their ability to develop independence is more complicated. Troubled adolescents become more dependent on their parents: When a suicidal, depressed kid can’t function on their own, they need parents to step in. But this flies in the face of their need for autonomy. Depressed adolescents themselves are confused. On the one hand, they want more independence, but on the other hand, they know they need more support. They also often lack the skills to negotiate this balance. Our job in the therapy process is to teach adolescents emotion-regulation skills and teach parents new attachment-promoting parenting skills, so the family can renegotiate these development challenges.

Suzanne: Parents have good intentions, but the child doesn’t always experience their actions as protective or as building trust. ABFT is about helping parents get their intentions across so that their teens experience the true intent. We’ve worked with a lot of parents who have felt blamed by clinicians. The parents we work with feel cared for rather than blamed. We look at the strengths of the family and work to build those up.

Guy: The parents are as much our patients as the kids are. We view them as needing our help, empathy, and guidance. Every parent wants to be a good parent—it’s what John Bowlby [who formulated attachment theory] called the “caregiving instinct.” We believe that to be true of every parent we work with, but we also recognize that the way they go about it sometimes may not be working well. And that could be about their own histories of abandonment or other attachment issues, current stressors, or other things that are getting in the way of being the parent they want to be.

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How does attachment theory inform ABFT?

Guy: Bowlby was trained in Freudian theory, where the thinking is that early childhood experiences determine your psychological strengths and weaknesses. The idea is that what gets laid down in the early years is what you’re stuck with, and you have to spend your life coming to terms with it and learning to live with it. One of Bowlby’s innovations was to see that because parent-child relationships have such an important role in shaping a child’s view of themselves and of others, that this interactional process is life-long. Relationships are always shaping our experience.

When we see adolescents, often they’re struggling with things from the past that have left a residue on how they feel about themselves and others. And some parents are struggling with things from their past that make it difficult for them to be good parents. When parents become more aware of these intergenerational patterns, it frees them to make better parenting decisions. It can also help them become more sensitive to what their child might be struggling with.

At the same time, when adolescents feel their parents are being more receptive and understanding, it begins to revive their hope for improvements in the relationship. Adolescents begin to rebuild a sense of safety, attachment, and commitment to their parents. As a result, they feel they can turn to their parents for help when they are hurting. They also feel more invested in maintaining a better relationship with their parents, so they are more likely to take responsibility for their own actions and take care of their relationship with their parents.

That’s the fundamental premise of Newport Academy’s mission: Parents have a chance to learn skills to help them better understand their adolescents, and both parents and kids begin to rediscover the healthier parts of themselves and create better relationships.

Suzanne: I want to be clear that we’re not talking about kids with Reactive Attachment Disorder—which is the often the result of early deprivation—but rather insecure attachment and other mental health issues. ABFT is not tested for Reactive Attachment Disorder.

What additional modalities influenced the development of ABFT?

Guy: We always talk about standing on the shoulders of giants. We are clearly influenced by other mental health traditions and psychotherapy models. These include Salvador Minuchin’s Structural Family Therapy, Les Greenberg’s Emotion Focused Therapy, Sue Johnson’s Emotionally Focused Therapy for Couples, Ivan Boszormenyi-Nagy’s Contextual Family Therapy, and Howard Liddle’s Multidimensional Family Therapy. In addition, ABFT includes elements of other therapy models—such as Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Behavioral Activation. We’re eclectic in that regard—we’re not overly prescriptive or rigid. The ABFT model provides a general framework and structure within which we can use many different skills to facilitate change.

How ABFT Addresses Teen Mental Health

How do attachment therapy techniques specifically target adolescent depression, trauma, and suicidal ideation?

Guy: Suicidal and depressed teens feel very isolated, and they worry that they are a burden to the people around them. ABFT aims to strengthen the safety net of the family so it serves as more of a cushion or safe haven in which these kids can turn to others for help, get things off their chest, and work through them. In doing that, they reduce a lot of their stress along with their sense of isolation and of being a burden.

At a more pragmatic level, ABFT is about supporting parents to monitor the safety of their kids. We sometimes talk about “swaddling” teenagers. Depressed teens are vulnerable, and parents need to closely monitor them in a loving, supportive way, until they learn to self-regulate. Then parents can begin to give them more independence and freedom. A lot of teens feel very taken care of by their parents following the ABFT process, which is a huge relief to them.

Suzanne: For many of our clients, conflicts and issues with their parents are driving their depression, so addressing those conflicts helps reduce one of the possible stressors leading to depression. When teens feel more supported by parents, they allow parents to help them address depression-causing stressors, like bullying, school failure, or relationship disappointments.

Guy: Parents learn to step back and think about a realistic plan rather than expecting these depressed and traumatized kids to get As in honors classes. We help parents take stock and be more realistic about their goals. Maybe straight As and honors classes are not the most important thing for a tenth grader who is struggling with suicidal thoughts. Helping resolve problems that inhibit the desire to live seems like a much more important short-term goal.

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What does research show regarding the efficacy of ABFT vs. other types of family therapy?

Guy: One of the strengths of our work is that we’ve been doing research on it for nearly 20 years, including a number of clinical trials testing its effectiveness against other approaches. ABFT has shown some very strong results in preventing relapse of suicide attempts and providing a protective factor that lasts longer than the therapy itself. We’ve also done a lot of work looking at in-session processes: How do you engage a difficult adolescent? How do you motivate a parent who’s worn out and fed up? When do you bring in other relatives and siblings? We’ve done in-depth work around the particular mechanisms of the therapy, which has led to the development of a structure of tasks, processes, and goals.

Suzanne: ABFT has shown success with depressed adolescents with a history of sexual trauma, as well as suicidal ideation. In CBT and medication studies, kids with this presentation have not done well. We’ve also been adapting the approach for LGBTQI adolescents. Research shows that parental support is a big buffer against suicidal risk and suicidal thoughts for this population. If teens are still at home, it’s really important to work on making the home safe for them, even if their parents don’t change their beliefs.

The ABFT Structure and Approach

How important is it for therapists to implement the ABFT tasks in the appropriate sequence?

Suzanne: The structure of the tasks is based on our research looking at how to meet therapeutic goals most effectively. But there is also flexibility in the structure. We have to meet families where they’re at. Sometimes you may have to skip ahead or move backward. Sometimes an adolescent won’t be ready to meet with their parents after the individual sessions, so the therapist might have to do more work with them to help them understand why that’s the necessary next step. Or you might not be able to meet with both parents first, so you start with one and then bring the other one in later. The tasks are there to provide an outline for an ideal process, but we look at every situation on a case-by-case basis.

Guy: The model has a lot of structure, which is really its gift. Family therapy can be a very vague and unwieldy activity because so much is going on and there are so many people’s needs to address. The ABFT model provides a scaffold to help therapists stay organized around the essential things. But it also allows for tremendous creativity on the part of the therapist. It’s not a cookie-cutter or behavior-management approach. It’s a roll-up-your-sleeves, trauma-informed, emotion-focused modality that has both depth and structure.

How do practitioners use family therapy techniques to improve communication within the family?

Suzanne: The foundation is that they have to feel safe with the therapist first. The therapist’s relationship with the family is vital. If kids don’t feel safe opening up with us, it will be difficult for them to turn to their parents and open up to them. The parents also have to trust us and feel that we value and respect them as parents and as people. Once trust is established, we work to identify some of the core relational ruptures that have damaged trust (e.g., trauma, divorce, parent-child conflict etc.). Then we teach everyone skills to they can have manageable conversations, and bring them back together to discuss these difficult topics. Working through these kinds of issues usually helps dissipate hostility and increase trust. With this new foundation, families are able to begin addressing the day-to-day challenges of life without them becoming a battle.

Guy: The kids we work with haven’t felt comfortable expressing what’s upsetting them, or they don’t know how to express it. To put it very simply, ABFT is about helping these kids get things off their chest, and helping parents be more receptive to what they’re hearing. A classic example is divorce. A lot of kids struggle when there’s a difficult divorce, and sometimes parents don’t want to talk about it because they’re worried it will upset the kids. So the kids are full of fantasies about why it happened and what happened, and often they think it’s their fault. ABFT gives parents skills to wade into topics like this. Children then learn they can talk about these things and survive, and even be closer. Kids learn skills to manage their emotions, regulate themselves, and handle conflict better. We use hot topics as opportunities to teach both parents and kids how to communicate better and handle problems better.

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Is ABFT a short- or long-term intervention, and are the benefits sustainable over time?

Suzanne: For teens and young adults who are in residential treatment, this work can be the starting point of repairing the relationship. Then the family can continue the process with another therapist. We have follow-up research showing that the results do sustain in many families.

Guy: Our work has tended to be relatively short term, partly because we do it in a research context. But we’ve had families call a year later and say something like, “Our daughter just left for college and that couldn’t have happened without you.” Or they sometimes say, “My kid is back in the hospital, but the first time this happened, it was a crisis. This time, she came to me and told me she was hurting and needed help, and we went to the ER together. Even though she’s still struggling, we are a team. She comes to me for help, and that has made all the difference.”

Sources:

Fam Process. 2016 Sep;55(3):595-610.

J Marital Fam Ther. 2016 Jan; 42(1): 91–105.

J Fam Psychol. 2012 Aug;26(4):595–605.