Attachment-Based Family Therapy is an evidence-based approach for treating depression and preventing suicide in adolescents. This therapeutic modality utilizes a structured methodology that focuses on revitalizing empathy and authentic connection within the parent-child relationship.
“Parenting is built on two pillars—love and empathy, and structure and protection,” says Guy Diamond, PhD, co-creator of Attachment-Based Family Therapy (ABFT) and a consultant and clinical trainer for Newport Academy. “Empathy is one of a parent’s most important tools for facilitating a child’s development. It allows them to understand the inner life of their child, to perceive what they’re thinking and feeling and help them become aware of their emotional landscape.”
A key element in Newport Academy’s approach to treatment, ABFT aims to repair damage in the family system so teens feel safe turning to their parents for support. Hence, teen mental health improves and the risk of teen suicide goes down. Consequently, ABFT is a powerful approach to supporting adolescent well-being, says Barbara Nosal, PhD, LMFT, LADC, Newport Academy’s Chief Clinical Officer.
“In our experience, parents and teens both desire the same thing—closer, more meaningful relationships with one another. They just don’t know how to begin,” says Dr. Nosal. “ABFT provides the family with a path to sustainable healing. Therefore. Newport Academy is the first residential treatment program to adopt ABFT as our family therapy model and fully integrate ABFT into our clinical program.”[/vc_column_text][/vc_column][/vc_row]
The Link Between Family Attachments and Mental Health
Genetics and biology influence adolescent mental health. But family relationships and attachments have a tremendous impact on teen well-being.
“The family is the secure base for child development,” Dr. Diamond says. “It is the schoolroom of life, where kids learn about themselves, learn how to trust people, and learn how to manage their emotions better. That’s why Newport sees the family as so important in the healing and growing process of our young patients.”
Hence, according to ABFT philosophy, the following family circumstances have a significantly negative impact on teen mental health:
- Family conflict
- Harsh criticism
- Other family traumas.
In addition, the impact of these issues within the family is compounded when parents fail to comfort and support teens. Moreover, parents sometimes fail to help teens process these disturbing experiences. Hence, the result may be relational trauma, teen PTSD, teen depression, and/or other adolescent mental health conditions. A teen mental health problem then further strains the parent’s resources.
“It’s hard enough to raise an adolescent, let alone a depressed adolescent,” Dr. Diamond notes. “When parents get burnt out, it’s harder for them to access empathy as one of their parenting tools.”
But when adolescents perceive their parents as caring, protective, and trusting, the family becomes a strong foundation. Therefore, family relationships help teens weather life challenges.
“The nature of the original attachment bond between a child and their parents (or primary caregivers) is critical. When there is not a secure attachment with the primary caregivers, there is insecurity and anxiety. Furthermore, it determines a child’s ability to form authentic connections.”
—Heather Senior Monroe, Director of Program Development at Newport Academy
The Development of Attachment-Based Family Therapy
Attachment-Based Family Therapy is the first adolescent family therapy designed to target family processes associated with teen depression and suicide. It grew out of various mental health modalities and philosophies.
Most important, John Bowlby’s attachment theory inspired and influenced ABFT. This theory posits that humans have an inherent biological desire for meaningful relationships.
Consequently, interpersonal relationships within the family system profoundly affect teen mental health. Therefore, Attachment-Based Family Therapy is a trust-based and emotion-focused psychotherapy model.
Furthermore, the following modalities also influenced the ABFT model:
- Structural Family Therapy
- Multidimensional Family Therapy
- Emotionally Focused Therapy.
Dr. Diamond, along with Gary M. Diamond and Suzanne A. Levy, defined the parameters of ABFT. Their book Attachment-Based Family Therapy for Depressed Adolescents is known as the ABFT manual. The American Psychological Association published the book in 2014.
How Attachment-Based Family Therapy Repairs Relationships
The structure of ABFT includes five distinct treatment phases. These phases are sometimes referred to as “treatment tasks.” In addition, each phase has clear goals and strategies. Therefore, ABFT provides a clear road map to healing and recovery. Each step of the process repairs ruptures in the attachment relationship.
“A challenge with other family therapy approaches is that when parents admit their child to treatment, parents are often focused on their child’s behavior, resulting in parental anxiety, anger, and resentment,” says Dr. Nosal. “ABFT provides the opportunity for the family therapist to work individually with parents to identify their own childhood attachment ruptures. This process moves parents away from being focused on behavior to being emotionally focused, resulting in greater understanding of their child’s experience and feelings.”
In addition, Dr. Diamond says, the ABFT process recognizes parents for their accomplishments, reminds them of our strengths, and revives their innate caregiving instinct, so they can be the kind of parent they want or need to be. “We help parents establish warmth and structure, empathy and expectation. Then kids have the freedom to access their own pain and confusion and figure out who they are, with the support of a secure base.”
The Five Treatment Phases of Attachment-Based Family Therapy
- Reframing the therapy to focus on interpersonal development: The ABFT therapist shifts the focus away from symptoms and toward the improvement of the parent-child relationship. The first goal of treatment is to discover what damaged the trust in the relationship.
- Building alliance with the adolescent: In individual sessions with the adolescent, the therapist learns about the teen’s strengths and interests. Moreover, the therapist helps the teenager to understand and articulate the ruptures that occurred in their relationship with their parents.
- Forging an alliance with the parents: The therapist’s next task is to build an alliance with the parents in sessions without the adolescent. Hence, by offering empathy and support, the therapist creates trust and connection and helps parents access their own empathic instincts. Furthermore, the therapist may work with the parents to explore their own attachment issues from childhood.
- Facilitating conversations to resolve attachment ruptures: This is the central mechanism of ABFT. When adolescents and parents are ready, the therapist brings them together to discuss the teen’s concerns. The therapist guides the adolescent to express their grievances—in a mature, calm way. In addition, the therapist encourages the parents to express empathy and understanding. This exchange lays the foundation for a more securely attached relationship between parent and child. Moreover, when teens feel heard, they are more able to understand and empathize with what their parents are feeling.
- Promoting autonomy and competency in the adolescent: The last phase of ABFT is helping teens to find appropriate autonomy and independence. Therapists encourage teens to socialize and pursue activities outside the home. Thus, they gain a sense of empowerment and confidence. Moreover, therapists guide parents to support their child—but also allow them to make their own choices and take responsibility for their own behaviors.
“When a teen receives empathy and validation from their parents, they feel safe and supported to be more open and honest overall.”
—Barbara Nosal, PhD, LMFT, LADC, Newport Academy Chief Clinical Officer
What Is a Secure Attachment?
According to attachment theory, a secure attachment develops when parents are sensitive to a child’s needs. As a result, secure attachment supports a child’s development. This leads to good emotional regulation skills. Moreover, it increases adolescents’ feelings of self-worth.
Therefore, in step four of the ABT process, therapists foster attachment therapy experiences. Hence, adolescents receive love and support from their parents in these sessions.
Consequently, these experiences reinforce the primal attachment between parent and child. And this reinforcement creates a solid foundation that protects the teen against depression and suicide.
“Attachment Theory rests on the assumption that a child’s sense of security in life depends on parents being available and protective. For adolescents in particular, secure attachment nurtures healthy development, while insecure attachment has repeatedly been associated with depression and other kinds of functional problems.”
—Guy S. Diamond, PhD, principal researcher and coauthor of Attachment-Based Family Therapy for Depressed Adolescents
Research on Attachment-Based Family Therapy for Teen Depression
In a prominent study on the efficacy of ABFT for adolescent depression, teens were randomly assigned to 12 weeks of ABFT or a six-week control group. The control group did not receive ABFT.
Following treatment, 81 percent of the patients treated with ABFT no longer met the criteria for major depressive disorder (MDD). Moreover, 87 percent continued to not meet criteria for MDD six months after treatment ended.
In addition, researchers found that ABFT had the following positive results for adolescents:
- Significant decreases in rates of depression diagnosis
- Reduced severity of depression and anxiety symptoms
- Decreases in feelings of hopelessness
- Lower incidence of suicidal ideation
- Increased attachment to their mothers.
“ABFT seems to be a viable and effective treatment for youths struggling with depression. As judged from the results of this pilot work, it appears that resolving core family conflicts and past traumas and strengthening adolescent attachment to and trust in parents can decrease depression in adolescents.”
—Guy S. Diamond, PhD, and his research team
Attachment-Based Family Therapy and Suicidal Ideation Study
Attachment-Based Family Therapy is also effective in reducing suicidal thoughts in teens. In another study, Dr. Diamond and his team worked with suicidal adolescents between the ages of 12 and 17.
Subsequently, youth treated with Attachment-Based Family Therapy demonstrated significantly greater and more rapid reductions in suicidal ideation during the treatment. And these improvements held steady six months after treatment as well.
Moreover, treatment was four times as likely to be successful for these teenagers.
Furthermore, ABFT provided more rapid relief from depressive symptoms than conventional care. And this is an important advantage when youth are at risk for suicide, as the researchers noted.
Attachment-Based Family Therapy for Anxiety
ABFT is also used for working with adolescents with anxiety disorders. This approach combines ABFT with Cognitive Behavioral Therapy. The basic structure of the five tasks is modified for adolescents with anxiety. The four main processes explore parental beliefs about anxiety, family modeling of anxious behavior, encouragement of avoidance, and parents’ psychological control related to family conflict.
In families with anxious adolescents, parents encourage teens to avoid behaviors that produce anxiety. Moreover, they attempt to control their teenager’s experiences in order to prevent symptoms of anxiety. As a result, teens become overly dependent on parents.
Hence, Attachment-Based Family Therapy for teen anxiety focuses on identifying parents’ own anxieties and fears. Also, how these might affect their children. Moreover, therapists help teens recognize how family dynamics affect their anxiety and their ability to be independent. Then parents and teens come together to discuss how to move forward with greater harmony.
ABFT as an Adaptable Approach
Moreover, ABFT is adaptable to meet varying lengths of stay and levels of care, says Dr. Nosal. Thus, ABFT can be adapted for use during a 30-day stay in residential treatment or for longer stays. And it can also be adapted to support teens and families during the transition from residential treatment to a Partial Hospital Program (PHP) or Intensive Outpatient Program (IOP).
In summary, Attachment-Based Family Therapy is a scientifically validated and effective clinical modality. It is proven to heal the family system. Consequently, as a result of stronger family relationships, teens recover from depression and suicidal ideation.
“At Newport Academy,” Dr. Diamond says, “the family is part of the medicine.”
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American Psychological Association
J Am Acad Child Adolesc Psychiatry. 2002 Oct;41(10):1190–6.
J Am Acad Child Adolesc Psychiatry. 2010 Feb;49(2):122-31.