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.

The Underpinnings of ABFT

Are there varied types of family therapy?

Guy: In the beginning, the main goal was to help parents provide structure and leadership in the family in order to manage the kids’ out-of-control behaviors. Regardless of the diagnostic problem, parents needed to provide organization for the family.

What inspired the creation of ABFT?

Guy: After working with kids with histories of trauma depression, suicide, and anxiety, we found it wasn’t about adding more structure, limits, or rules. Instead, ABFT is a framework that unpacks parents’ instinctual desire to protect their children and children’s instinctual desire to turn to their parents for love and protection.

We were inspired to find out what stood 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?

The healthiest teens stay connected while also developing autonomy and independence. For kids who have mental health problems, their ability to develop independence is more complicated. When a suicidal, depressed kid can’t function on their own, they need parents to step in, which directly conflict with their need for autonomy. Our job is to teach adolescents emotion-regulation skills and to teach parents new attachment-promoting parenting skills.

Suzanne: Parents have good intentions, but these actions are often misunderstood by the child. ABFT aims to solve this issue. We’ve worked with many parents who have felt blamed by clinicians. The parents we work with feel cared for –we look at the strengths of the family and work to build those up.

Guy: We view the parents as much our patients as the kids—both need 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.” Every parents has their own history 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, and we’re here to help them navigate through a solid approach.

How does attachment theory inform ABFT?

Guy: Bowlby was trained in Freudian theory which states that early childhood experiences determine your psychological strengths and weaknesses. Because parent-child relationships have such an important role in shaping a child’s view of themselves and others, this interactional process is continuous.

Often times, adolescents are struggling with issues from the past, which can also be the case for parents. When parents become aware of these intergenerational patterns, it frees them to make better parenting decisions and be more sensitive towards their child.

That’s the fundamental premise of Newport Academy’s mission: Parents have a chance to learn skills to better understand their children, and the entire family unit discovers a healthy version of themselves.

Suzanne: To be clear, 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 are clearly influenced by other mental health traditions and psychotherapy models, including 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 Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Behavioral Activation. We’re eclectic in that regard. 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 isolated, and worry they are a burden to others. ABFT aims to strengthen the family safety net so they can turn to others to work through their issues. Ultimately, this reduces their stress, the sense of isolation, and the feeling of being a burden.

ABFT supports parents in monitoring their kid’s safety. Depressed teens are vulnerable, and parents need to be loving and supportive until they learn to self-regulate.

Guy: Parents learn to manage expectations. 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.

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

Guy: We’ve been doing research for nearly 20 years, including a number of clinical trials. ABFT has shown strong results in preventing relapse of suicide attempts and providing a protective factor which lasts longer than therapy itself. 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 adapted the approach for LGBTQI adolescents. Research shows that parental support is a big buffer against suicidal risk and suicidal thoughts for this population. Even if their parents don’t change their beliefs, it’s important to make their home feel safe.

The ABFT Structure and Approach

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

Suzanne: The structure of tasks is determined by the most effective way to meet therapeutic goals, which is flexible in nature. The tasks are provide an outline for an ideal process, but we look at every situation individually.

Guy: Family therapy can be a very vague and unwieldy activity because there are so many moving parts. The ABFT model allows for tremendous creativity from the therapist. 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 first step is feeling safe with the therapist. We also need trust and respect from parents. Once this is established, we work to identify the core relational ruptures that have damaged trust (e.g., trauma, divorce, parent-child conflict etc.). Then we teach skills so the family can have conversations about the difficult topics, which dissipate hostility and increase trust. With this new foundation, families can address the day-to-day challenges without it becoming a battle.

Guy: ABFT is about helping 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 through this transitional time and some parents refuse to talk about it because they’re worried it will upset the kids. As a result, kids are left in the dark and may even blame themselves. ABFT gives parents the skills to address these types of situations.

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, ABFT can be the starting line for a longer journey.

Guy: Though our work is relatively short term because of its research focus, ABFT has long-term benefits. We’ve had families call a year later and say “Our daughter just left for college and that couldn’t have happened without you.” Other times they say, “My kid is back in the hospital, but this time she told me she was hurting and needed help. Even though she’s still struggling, we are a team which 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.