Diamond Et Al-2016-Family Process PDF
Diamond Et Al-2016-Family Process PDF
Diamond Et Al-2016-Family Process PDF
Empirical Support
GUY DIAMOND*
JODY RUSSON†
SUZANNE LEVY†
INTRODUCTION
595
Family Process, Vol. 55, No. 3, 2016 © 2016 Family Process Institute
doi: 10.1111/famp.12241
596 / FAMILY PROCESS
patient’s trust in others and confidence in oneself. However, the individual therapist’s
empathic and consoling statement of “it is not your fault” pales in comparison to the vali-
dation a child receives when the parent says, “it was not your fault.” In family therapy,
the actual family members sit in the room together with the opportunity for each person
to better understand and change their role in the family process. Therefore, from an
attachment perspective, individual and relational change occurs through the restoration
or refurbishing of healthy, trustworthy, reliable, and emotionally sensitive parent–child
relationships (Kobak & Sceery, 1988).
Attachment-based family therapy (ABFT; Diamond et al., 2014) capitalizes on the
innate, biological, and existential desire for meaningful and secure relationships. There-
fore, we do not start therapy with problem solving or behavioral management. Instead,
like emotion-focused couples therapy (Johnson, 2004), we work to uncover what experi-
ences (e.g., abuse) and relational processes (e.g., harsh criticism) have damaged trust in
family relationships. We uncover these “traumas” and help the family have an authentic,
honest, emotionally engaged, and regulated conversation about these relational disap-
pointments. Topics might include varying degrees of abuse, neglect, abandonment, or life
circumstances like divorce, parental depression, or loss. At one level, these conversations
help individuals resolve or work through these traumas. At another level, these conversa-
tions provide an opportunity for adolescents and parents to practice newly learned rela-
tional skills. At a third level, this conversation enacts a corrective attachment experience:
children express vulnerable thoughts and feelings and parents remain available, respon-
sive, and emotionally attuned. Engineering these attachment-promoting conversations
improves views and expectations of self and others, which, in turn, impacts how family
members interact together.
Thus, we developed ABFT to explicitly target the improvement of attachment security
as the primary mechanism of change. Still, ABFT is rooted in four family-based clinical
traditions. From structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981),
we rely on the concept of enactment. These in-session, in vivo experiences of change con-
solidate psychological and interpersonal learning. From multidimensional family therapy
(Liddle, 2010), we borrow the framework of using psychological science to inform the selec-
tion of treatment targets and our understanding of how to facilitate the therapeutic pro-
cess. From emotion-focused individual (Greenberg & Paivio, 2003) and couples therapy
(Johnson, 2004), we incorporate a focus on emotions as a key ingredient of therapeutic
change. Finally, from contextual therapy (Boszormenyi-Nagy & Krasner, 2013), we bor-
row the concept of trust as the basic fabric of family life, without which behavioral and
interpersonal problem solving will fail.
Attachment theory, however, provides the primary theoretical and clinical framework
of ABFT. Attachment theory posits that when parents are sensitive and available, chil-
dren grow up with the confidence that parents will support and protect them, while also
feeling worthy of being loved and protected. From these trustworthy relationships, chil-
dren also learn to regulate their emotions. For instance, children use parents to soothe
their anxieties and fears, thus learning to down regulate negative affect and to feel com-
fortable expressing vulnerable emotions. Over time, children begin to internalize these
relational expectations as internal working models, setting the foundation for what they
will expect from others in future relationships.
The role of secure attachment is no less important in adolescence. Rather than separa-
tion and individuation (e.g., Erikson, 1968), the central task of adolescence is to maintain
attachment while negotiating autonomy. Adolescents who keep this balance do better in
school, have fewer deviant peer relationships, and even have better health outcomes
(Allen, Moeller, Rhoades, & Cherek, 1998; Kobak, Cassidy, Lyons-Ruth, & Ziv, 2006;
Lynch & Cicchetti, 1991; Rosenstein & Horowitz, 1996). When adolescents do not have a
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DIAMOND, RUSSON, & LEVY / 597
safe and protective parenting environment, they lack this essential developmental context
where interpersonal problem-solving and emotion regulation is learned, thus putting
them at risk for a number of psychiatric disorders (Cicchetti & Toth, 1995; Sheeber, Hops,
& Davis, 2001).
therapist shifts attention to promoting the adolescent’s autonomy (e.g., school, hobbies,
and work) and/or working through other causes of depression/suicide, such as being bul-
lied or divorce. The therapist pushes the adolescent to take developmentally appropriate
responsibility for himself or herself while challenging the parents to find the right balance
of support and encouragement. Conversations may also focus on identity formation topics,
including race, gender, sexual identity, and/or religion.
ABFT RESEARCH
Although ABFT operationalizes family therapy processes that have relevance for many
disorders, most of our research has focused on depression and suicide, specifically for low-
income, minority youth. Depression may be the most common disorder for adolescents in
mental health agencies, yet few family interventions models have been tested with this
population. Youth suicide is less common, but more severe in its consequence and thus
has offered an interesting challenge for intervention development. For both depression
and suicide treatment, cognitive-behavioral therapies, with or without medication, have
been the primary modalities investigated.
Based on 15 years of research, ABFT is now listed on the National Registry of Empiri-
cally Proven Practices (http://www.samhsa.gov/nrepp). This registry catalogs all the treat-
ments that have received some level of empirical evidence and are ready for
dissemination. Below, we review these studies including outcome, efficacy, effectiveness,
and process research. The majority of clinical trials have been conducted with low-income,
minority populations at the Center for Family Intervention Science at Drexel University,
formerly at the Children’s Hospital of Philadelphia and University of Pennsylvania,
Department of Psychiatry. A majority of the process studies have been led by Gary Dia-
mond, both at out center and at Ben Gurion University in Israel.
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DIAMOND, RUSSON, & LEVY / 599
waitlist, nine of the waitlisted subjects still met eligibility at the end of 6 weeks and were
offered treatment.
Of the 16 treatment cases, 13 (81%) no longer met criteria for MDD at posttreatment,
while 7 (47%) of the 15 patients on the waitlist who completed the diagnostic interview no
longer met criteria for MDD post-waitlist (2[1] = 4.05, p < .04). Although there were not
significant differences between the groups on mean Beck Depression Inventory (BDI)
scores posttreatment, there was a difference between treatment conditions with regard to
the number of adolescents who endorsed posttreatment BDI scores at a nonclinical level
(BDI < 9, 2[1] = 6.37, p = .01). Sixty-two percent of the adolescents treated with ABFT
had a BDI of 9 or less compared to 19% of those on the waitlist condition. At six-month fol-
low-up, 87% of the treated sample no longer met criteria for MDD and showed significant
reductions in depression, anxiety, and negative family functioning (cohesion and conflict).
Finally, in terms of treatment retention, 63% attended nine or more sessions, a high reten-
tion rate for a population typically characterized by high levels of early attrition (Mano,
Davies, Klein-Tasman, & Adesso, 2009).
Fully powered randomized control trial
With a grant from the Centers for Disease Control, we screened and treated suicidal
adolescents identified in primary care with the goal of diverting youth from going to the
emergency department. Several large primary care sites in our hospital offered to screen
and refer patients. This was a study of treatment integration, not collocation. Most suicide
studies focus on suicide attempters. In contrast, we focused on adolescents with clinical
levels of suicide ideation and depression; a much larger population, but no less troubling
to patients, families, and health-care providers. To increase the severity of the sample,
patients also had to exhibit elevated depression.
In this study (Diamond et al., 2010), 66 adolescents were randomized to 14 weeks of
ABFT or enhanced usual care (EUC). EUC involved assistance in obtaining a therapist in
the community, weekly tracking of depression and suicidal ideation, and access to a 24-
hour crisis line. For an early study of model validation, EUC was an ethical control group
without being a fully developed alternative treatment. The sample was 83% female and
adolescents ranged in age between 11 and 18 years (M = 15.20, SD = 1.61). Of the entire
sample, 74% identified themselves as African-American, 15% as Caucasian, 3% as His-
panic/Latino, 3% as biracial, and 5% as “other.” In addition, 73% came from single-parent
families and 43% lived on less than $30,000 a year. Sixty percent of the adolescents
reported having made a suicide attempt in their lifetime.
Compared with EUC, youth treated with ABFT exhibited significantly greater and fas-
ter reductions in suicidal ideation during treatment. These differences persisted at follow-
up with a large effect size of .97. ABFT was also associated with greater rates of clinical
recovery on suicidal ideation posttreatment. These findings were strengthened by the con-
sistency across self-report and clinician ratings. At the time, this was one of the few stud-
ies to demonstrate that a research treatment was more effective than treatment as usual
(TAU) for reducing suicidal ideation in adolescents (Ougrin, Tranah, Stahl, Moran, &
Asarnow, 2015). ABFT was even effective with the most severe youth presenting with
comorbid anxiety and a history of multiple suicide attempts. A secondary analysis showed
that youth with a history of sexual abuse also responded well to treatment (Diamond,
Creed, Gillham, Gallop, & Hamilton, 2012), a finding not supported in several CBT or
CBT + medication studies (Asarnow et al., 2009; Barbe, Bridge, Birmaher, Kolko, &
Brent, 2004; Beautrais et al., 1996; Shirk, Kaplinski, & Gudmundsen, 2009).
Results also indicated that ABFT was associated with greater rates of clinical recovery
and treatment retention. At posttreatment, 87% of patients receiving ABFT reported sui-
cidal ideation scores not only below the clinical cutoff but also in a range consistent or
below that of a nonclinical sample of similar demographics (Reynolds & Mazza, 1999). For
EUC, only 51% achieved this level of recovery. Benefits were maintained at follow-up with
a strong effect size (OR = 4.41). This study was a breakthrough for ABFT. As one of the
only treatments showing success with suicidal youth, it helped put ABFT, and family
interventions, on the research map for adolescent depression and suicide. A major limita-
tion of the CDC study was that EUC had a low treatment dose (mean = 2.87 sessions),
while ABFT had a higher dose (mean = 9.71 sessions). Given this difference, we could not
be confident that the unique mechanisms of ABFT were accounting for the greater
improvement, or if it was an artifact of dose differential.
Second fully powered randomized control trial
To control for the low dose in the EUC sample, we obtained funding from NIMH to test
ABFT against nondirective supportive therapy (NST; Brent & Kolko, 1991). To control for
parent involvement, we added a four-session family psychoeducation component to the
NST. To further control for common factors across conditions, we used a crossover design
where the same therapists provided both treatments. In this design, patients in both treat-
ments received the same degree of empathy and support, but patients in the ABFT condi-
tion also received the active ingredients inherent to the model. To test these purported
mechanisms of change, we used the adult attachment interview (George, Kaplan, & Main,
1985) and a family interaction task as pre- and posttreatment outcome. This allowed us to
test whether ABFT changes attachment expectations and improves family interactions,
and whether or not these changes mediate long-term outcome. The results of this study
will be available within the next 2 years.
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DIAMOND, RUSSON, & LEVY / 601
Effectiveness Research Project
Our first dissemination study explored the feasibility of training therapists and evalu-
ating depression in a hospital-based, outpatient mental health clinic in Stavanger Norway
(Israel & Diamond, 2013). Research therapists came to the United States for the introduc-
tory training and then were subsequently supervised by a certified ABFT supervisor in
Norway. Three therapists were trained and credentialed to provide ABFT. Adolescents
were referred to the project by central intake. Adolescents were included in the study if
they scored a 14 or greater on the Hamilton Depression Rating Scale (HAM-D; Hamilton,
1960) and met criteria for major depression based on the Kiddie-Schedule for Affective
Disorders and Schizophrenia (Kaufman et al., 1997).
In total, 20 adolescents were randomly assigned to 12 weeks of ABFT or TAU (ABFT
n = 11, TAU n = 9). A little over 50% of the sample identified as female and all were
between the ages of 13 and 17 (M = 15.6). ABFT patients started treatment within
2 weeks after assignment and TAU families were referred back to central intake. Four of
the TAU cases received treatment and five did not. Results showed that there were no sta-
tistical differences on the BDI (z = .98, p = .32) for TAU cases that received treatment
and those that did not.
During treatment (12 weeks), youth in ABFT demonstrated significantly greater
improvement on the HAM-D (clinician-rated depression), than youth in TAU (z = 2.05,
p = .04). Analyses at posttreatment revealed that adolescents treated with ABFT had sig-
nificantly lower ratings on the HAM-D (z = 2.05, p = .04). There was also an eight-point
difference between treatment groups on the BDI, but it was not statistically significant
(z = 1.02, p = .23). However, the difference between the number of patients who moved
from clinical to nonclinical scores on the BDI at posttreatment was greater for adolescents
in ABFT at a marginally significant level, v2 [df1] = 2.88, p = .08.
The primary outcome from the study, however, was the increased knowledge about
resolving the implementation challenges. For example, shortly after the study began,
senior leadership at the hospital changed. New leadership was less invested in the study,
resulting in decreased enthusiasm and support for the study. In addition, two clinical fam-
ily psychologists left the hospital for other employment during the startup year. The new
hospital administrator mandated two other therapists to participate. One therapist was a
child, psychodynamic play therapist who usually left parents in the waiting room. These
kinds of barriers and our solutions are described in the article by Israel and Diamond
(2013). Similar implementation challenges were explored in three recent papers on imple-
menting ABFT in Australia (Diamond, Wagner, & Levy, 2016), Belgium (Santens,
Devacht, Dewulk, Hermans, & Bosmans, 2016), and Sweden (Ringborg, 2016). They
describe both nation-specific and universal challenges and solutions that stem from imple-
menting manualized therapies in new settings.
Adherence Research
As part of our 2002 study (Diamond et al., 2002), we developed the first ABFT adher-
ence measure (Diamond, Diamond, & Hogue, 2007). This study examined the fidelity of
ABFT for depressed adolescents. Trained observers used the Therapist Behavior Rating
Scale (3rd version; Diamond, Hogue, Diamond, & Siqueland, 1998) to code therapist
behaviors in 45 sessions of ABFT and 45 sessions each from two empirically based treat-
ments for adolescent substance abusers: multidimensional family therapy (MDFT) and
cognitive-behavioral therapy (CBT). Results indicated that ABFT therapists thoroughly
employed essential ABFT interventions, such as focusing on vulnerable affect, highlight-
ing attachment-related themes, and promoting adolescent-parent reattachment through
in-session enactments. In accordance with the sequential nature of the treatment, these
interventions were used more extensively during the early stage of treatment, when there
is a greater focus on repairing attachment. ABFT was perfectly discriminable from CBT,
with ABFT therapists using more restructuring and repairing attachment interventions
and CBT therapists using more signature CBT interventions, such as cognitive monitoring
and homework. ABFT was also discriminable from MDFT, with ABFT therapists placing
a greater emphasis on repairing attachment. These results helped validate that ABFT can
be learned and delivered with fidelity and can be differentiated from other treatments.
Interestingly, our thinking about adherence measures has evolved since this first study.
In the TBRS-3, we had one measure with five essential treatment processes, one for each
task. However, we do not expect the processes of one task to necessarily show up in other
tasks. Therefore, for our next generation of adherence, we developed an adherence mea-
sure for each task.
Process Research
In 2002, we wrote a “manifesto” about how to dismantle and test the proposed mecha-
nisms of ABFT (Diamond & Diamond, 2002). The ABFT model is built in a unique way
that actually isolates and amplifies processes in therapy. Each task has a primary change
mechanism and all sessions are associated with a task (e.g., a given task may take
3 weeks). This clinical model helps therapists remain clear about what processes they are
focused on at any given time in treatment. In addition, because we video tape each session,
we have a vast library of identified tasks, allowing us to design task- or process-specific
studies. The common factors are present in all tasks: empathy, support, admiration, accep-
tance, etc. We are developing coding tools for each task measuring the relative success of
that task (e.g., did we accomplish the desired goal of that task?). We will also develop a
battery of cross-task coding measures (e.g., emotional processing, and alliance). This will
allow us to evaluate if task success is associated with the success of future tasks or with
treatment outcome. These kinds of studies also helped us better understand the subtle
moment-by-moment processes, decision rules, and pitfalls within each treatment task.
Below, we review a few of the studies to demonstrate the kinds of methodologies and find-
ings that characterize this line of research.
Task 1: relational reframe
One study focused on the relational reframe task (Diamond, Siqueland, & Diamond,
2003). We sought to understand what processes were involved in shifting the treatment
focus from “adolescent as the problem” to “strengthening family relations as the solution.”
We developed a parent and adolescent pre- and postsession self-report questionnaire to
assess changes in clients’ views of responsibility for causing and correcting the problems
that brought them to treatment. The questionnaire was given to consecutive families at
the first treatment session at a community mental health clinic. The depressed adoles-
cents rated conflicts with parents as high in contributing to the problem. In addition, they
rated themselves and parents as very responsible and willing to help solve the problem.
Interestingly, parents rated themselves as low in contributing to the problem, but capable
and willing to help solve the problem. These data highlighted that the adolescent would
welcome an interpersonal treatment focus, but that parents needed more “winning over”
to a family-based treatment.
Because the families generally rated themselves high on having an interpersonal con-
struction of the problem pretreatment, the measure was not sensitive to postsession
change. Therefore, eight parents were interviewed after the first session using a videotape
recall method (Elliott, 1984). Among other things, parents approved of the initial siding
with adolescents, but expected more equanimity in later sessions. However, parents did
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DIAMOND, RUSSON, & LEVY / 603
like the treatment focus. The interviews more clearly elucidated the role that emotions
played in the relational reframe process. Eliciting strong, often vulnerable emotions asso-
ciated with these conflicts helped to challenge negative and often rigid cognitions about
problems and about the adolescents themselves (Greenberg & Safran, 1987). In particular,
the greatest clinical leverage occurred when parents came to understand how ruptures in
the parent–adolescent relationship contributed to the depression. Understanding the ado-
lescent’s desire to be loved helps resuscitate an emotional connection that motivates par-
ental commitment rather than abandonment.
Another study of the relational reframe explored its impact on parents’ problem con-
structions and the reciprocal impact of parents’ problem constructions on therapists’ use
of the relational reframe (Moran, Diamond, & Diamond, 2005). Looking across five early
therapy sessions, we found that relational reframes led parents to construct problems in
interpersonal terms in at least two of their six subsequent speech turns. There was partial
support for the hypothesis that reframes led to shifts in parents’ constructions, from
intrapersonal to interpersonal. In good but not poor alliance sessions, parents’ interper-
sonal problem constructions led therapists to use relational reframes.
In another study of the relational reframe, we examined the association between thera-
pist relationship-facilitating and attachment-oriented interventions on one hand and the
valence (i.e., positivity–negativity) of parents’ attitudes toward their depressed adolescent
on the other hand in a sample of 13 sessions of ABFT (Moran & Diamond, 2008). Parental
negativity is associated with the onset and maintenance of adolescent depression. Reduc-
ing parental negativity is a primary focus of ABFT. Lag sequential analyses revealed that,
in good alliance sessions, relationship-facilitating interventions, such as empathy and pos-
itive regard for the parent, were associated with parents’ nonnegative attitudes toward
their adolescent in the five speech turns subsequent to the intervention. Attachment-
oriented interventions, such as relational reframes, addressing core relational themes,
and highlighting vulnerable emotions, were also intermittently associated with nonnega-
tive parental attitudes in good alliance sessions. No such effects were evident for the com-
parison interventions. This study represents a first step in the process of testing specific
strategies for reducing parental negativity in family therapy.
Task 2: adolescent alliance
Currently, we have no completed studies on the adolescent alliance task. Several disser-
tations on this task, however, are underway.
Task 3: parent alliance
The parent–therapist alliance is an important factor in determining the effectiveness
and efficacy of therapy. Time alone with the parents helps therapists build a strong alli-
ance that helps motivate them to learn emotion-focused parenting skills. A strong alliance
with parents is also a robust predictor of treatment retention and outcome (Friedlander,
Escudero, Heatherington, & Diamond, 2011). We have conducted several process studies
about the parent alliance task.
In one study that included both Task 2 and Task 3, we sought to understand both
the contribution of general therapeutic alliance and specific ABFT alliance processes to
outcome (G.S. Diamond et al., 2003). Twenty-three individual sessions with adolescents
and 23 individual sessions with parents in the ABFT 2002 outcome study were
assessed using a modification of the VTAS (Hartley & Strupp, 1983) and a new mea-
sure with ABFT-specific items. For the adolescents, none of the ratings of VTAS were
significantly correlated with depression outcomes, but there was a trend toward associ-
ations between alliance and a decrease in parent–adolescent conflict. For the ABFT-
specific items, there was a trend for adolescent agreement on individual goals to be
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DIAMOND, RUSSON, & LEVY / 605
general. We hope to plan studies that will identify, dismantle, model, and evaluate how
these conversations go.
Mechanisms of Change
One underinvestigated area in family intervention science concerns testing of the pur-
ported mechanism of change. To address this in ABFT, Shpigel, Diamond, and Diamond
(2012) conducted a secondary analysis with data from our 2010 study. They sought to
explore the relationship between changes in parenting behaviors on one hand and changes
in adolescent attachment and psychological symptoms on the other hand. More specifi-
cally, the study examined whether ABFT was associated with decreases in maternal psy-
chological control and increases in maternal psychological autonomy granting from the
first session of therapy (Relational Reframe Task) to the fourth session of therapy (first
Attachment Task), and whether such changes were associated with changes in adoles-
cents’ attachment schema and psychological symptoms. Eighteen suicidal adolescents and
their mothers received 12 weeks of ABFT. Adolescents reported perceived maternal care
and control, attachment-related anxiety and avoidance, and depressive symptoms at base-
line and 6, 12, and 36 weeks. Results indicated that across the first four sessions, mater-
nal psychological control decreased and maternal psychological autonomy granting
increased. This increase in autonomy granting was associated with increases in adoles-
cents’ perceived parental care from pre- to mid-treatment and decreases in attachment-
related anxiety and avoidance pre- to posttreatment. Decreases in adolescents’ perceived
parental control during the treatment were associated with reductions in adolescents’
depressive symptoms from pretreatment to 3 months posttreatment. These results sug-
gest that ABFT impacts adolescents’ well-being and improves attachment to parents. Fur-
ther, this study lends support for specific change mechanisms underlying the treatment,
particularly in reducing parental control and criticism and increasing parental psychologi-
cal autonomy granting and care.
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DIAMOND, RUSSON, & LEVY / 607
and fears related to their adolescent’s minority sexual identity; (2) address the meaning,
implications, and process of acceptance for both parents and adolescents; and (3) heighten
parents’ awareness of subtle yet potent invalidating responses to their adolescents’ sexual
identity.
In Phase II, 10 suicidal LGB youth were offered 12 weeks of LGB-sensitive ABFT. Ado-
lescents’ report of suicidal ideation, depressive symptoms, and maternal attachment-
related anxiety and avoidance were gathered at pretreatment, 6 weeks, and 12 weeks
(posttreatment). Seven of the 10 families completed a full course of treatment. The study
showed that this population can be recruited and successfully treated with a family-based
therapy. Preliminary outcome data indicated significant decreases in suicidal ideation, F
(2, 14) = 38.16, p = .001, d = 3.76; depressive symptoms, F(2, 14) = 3.78, p = .05, d = .67;
and maternal attachment-related anxiety, F(2, 8) = 10.89, p = .005, d = 1.25; and avoid-
ance, F(2, 8) = 4.31, p = .05, d = 1.50. This is the first family-based treatment adapted
and tested specifically for suicidal LGB adolescents. Although promising, the results are
preliminary and more research on larger samples is warranted.
Anxiety Disorders
Attachment-based family therapy has also been tested to treat disorders other than
depression and suicidality. For example, ABFT was used in a sample of teens diagnosed
with anxiety disorders (Diamond, Diamond, et al., 2012; Siqueland et al., 2005). In this
study, ABFT and CBT techniques were combined to make a new treatment specifically for
anxious adolescents and their families. In Phase I, a manual was developed, therapists
were trained, and an open-trial pilot study was conducted to determine feasibility and
acceptability. In Phase II, a randomized design was used to determine the feasibility of
implementing individual CBT and CBT-ABFT. The majority of patients for this study
were recruited at the University of Pennsylvania, from an outpatient program dedicated
to treating adolescent anxiety and depressive disorders.
Outcomes showed that CBT-ABFT was successful in addressing adolescent anxiety as
assessed by clinically evaluated decreases in self-report of depressive symptoms (Hamilton
Anxiety Rating Scale; Hamilton, 1959) and anxiety symptoms (Beck Anxiety Inventory;
Beck, Epstein, Brown, & Steer, 1988). Forty percent of participants in CBT-ABFT no
longer met symptoms of depression or anxiety with 80% continued improvement at follow-
up. There were no significant differences between conditions for psychiatric symptoms;
however, those adolescents in the CBT-ABFT condition reported decreases in psychologi-
cal control, whereas those in the control group reported increases. This could suggest that
treatment gains could be further assimilated within the combined treatment, although
further research in this area is warranted (Siqueland et al., 2005).
CONCLUSION
Attachment-based family therapy is an empirically supported treatment designed and
developed specifically for repairing attachment ruptures that have damaged trust in the
parent–child relationship. ABFT focuses on family factors, such as parental rejection and
criticism, low parental warmth, and adolescent-parent conflict; all of which are associated
with a host of adolescent problems. The model aims to both help improve individual (ado-
lescents and parents) functioning and interactional processes that create a context for
individual development. ABFT has strong empirical support demonstrating the efficacy of
the model, as well as preliminary data regarding effectiveness. Additionally, ABFT has a
long history of process research that has helped us better understand some of the micro-
changes within the therapeutic conversation that contribute to treatment success or
failure. This research has set the foundation for our training program which supports the
dissemination of ABFT in eight different countries (www.abfttraining.com or http://www.-
drexel.edu/familyintervention/abft-training-program/overview/). ABFT is a proven treat-
ment for depressed and/or suicidal youth and their families. Additionally, ABFT seems to
have relevance for other presenting problems in a variety of clinical settings.
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