Tuesday, March 10, 2015

Attachment-Based Family Therapy (ABFT) for Depressed and Suicidal Youth: Interview with Guy Diamond, Ph.D., and Suzanne Levy, Ph.D.

[Episode 96] In today's Social Work Podcast I speak with two of the three developers of Attachment-based Family Therapy (ABFT), Guy S. Diamond, Ph.D. and Suzanne Levy, Ph.D. The third developer Gary M. Diamond (no relation to Guy Diamond) lives in Israel and was unavailable for the interview.

ABFT is the only family-based psychotherapy with empirical support for reducing suicidal ideation in youth. In today's interview, Dr. Diamond and Dr. Levy discuss the theory and practice of Attachment-Based Family Therapy. Dr. Diamond mostly covers theory and concepts, and Dr. Levy addresses the question of "what does the therapist actually do in the therapy room."

Download MP3 [50:36]


If you're interested in learning more about ABFT, you can buy the treatment manual Attachment Based Family Therapy for Depressed Adolescents, watch a free webinar http://youtu.be/KcwHznzq-S4, or attend a workshop (details on their website: http://drexel.edu/familyintervention/attachment-based-family-therapy/overview/)
ABFT is listed on the National Registry of Evidence-based Programs and Practices, also referred to as NREPP. According to NREPP, 
"Attachment-Based Family Therapy (ABFT) is a treatment for adolescents ages 12-18 that is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. The model is based on an interpersonal theory of depression, which proposes that the quality of family relationships may precipitate, exacerbate, or prevent depression and suicidal ideation. In this model, ruptures in family relationships, such as those due to abandonment, neglect, or abuse or a harsh and negative parenting environment, influence the development of adolescent depression. Families with these attachment ruptures lack the normative secure base and safe haven context needed for an adolescent's healthy development, including the development of emotion regulation and problem-solving skills. These adolescents may experience depression resulting from the attachment ruptures themselves or from their inability to turn to the family for support in the face of trauma outside the home. ABFT aims to strengthen or repair parent-adolescent attachment bonds and improve family communication. As the normative secure base is restored, parents become a resource to help the adolescent cope with stress, experience competency, and explore autonomy. 
ABFT is typically delivered in 60- to 90-minute sessions conducted weekly for 12-16 weeks. Treatment follows a semistructured protocol consisting of five sequential therapy tasks, each of which has clearly outlined processes and goals:
  1. Task 1: The Relational Reframe Task, with the adolescent and parents (or parent) together, sets the foundation of the therapy. After an assessment of the history and nature of the depression, the therapist focuses on relational ruptures. This shift pivots on the therapeutic question, "When you feel so depressed or suicidal, why don't you go to your parents for help?" The progression of this conversation leads parents and the adolescent to agree that improving the quality of their relationship would be a good starting point for treatment.
  2. Task 2: The Adolescent Alliance Task, with the adolescent alone, identifies relational ruptures in the family and links them to the depression. The adolescent is encouraged and prepared to discuss these often avoided feelings and memories with his or her parents.
  3. Task 3: The Parent Alliance Task, with the parents alone, explores their current stressors and their own history of attachment disappointments. These conversations activate parental caregiving instincts to behaviorally and emotionally protect their child, which helps motivate parents to learn and use new attachment-promoting parenting skills.
  4. Task 4: The Attachment Task, with the adolescent and parents together, creates an opportunity for the adolescent to directly express his or her thoughts and feelings about past and current relational injustices. Rather than defending themselves, parents help the adolescent fully express and explore these emotionally charged topics. This conversation helps the adolescent work through trauma, address negative patterns in the relationship, and practice new conflict resolution and emotion regulation skills.
  5. Task 5: The Autonomy Task, with the adolescent and parents together, helps consolidate the new secure base. In solving day-to-day problems, parents provide support and expectations and the adolescent seeks to develop autonomy while remaining appropriately attached to his or her parents." (http://legacy.nreppadmin.net/ViewIntervention.aspx?id=314)


Download MP3 [50:36]

 

Bios

Guy S. Diamond Ph.D. is Professor Emeritus at the University of Pennsylvania School of Medicine and Associate Professor at Drexel University in the College of Nursing and Health Professions. At Drexel, he is the Director of the Center for Family Intervention Science (CFIS) and the Director of the Ph.D. program in the Department of Couple and Family Therapy. He has received several federal, state and foundation grants to develop and test this model. Along with his co-authors, Drs. Gary Diamond and Suzanne Levy, Dr. Diamond has written the first book on ABFT, Attachment-Based Family Therapy for Depressed Adolescents, published by the American Psychological Association in October 2013.

Suzanne Levy, Ph.D. is the Training Director and a clinical child psychologist at the Center for Family Intervention Science (CFIS) at Drexel University.  Dr. Levy conducts ABFT training workshops and supervision for therapists involved in the center’s clinical trials, as well as therapists both nationally and internationally.  Dr. Levy has presented regionally, nationally, and internationally on ABFT, emotion coaching, child and adolescent therapies, adolescent depression, adolescent development, and adolescent substance use.  Dr. Levy’s personal areas of research interest have been related to ABFT and issues of child psychotherapy and behavioral health in primary care.  Dr. Levy is co-author on the ABFT manual, Attachment-Based Family Therapy for Depressed Adolescents.

Transcript

Introduction
Today’s episode of the Social Work Podcast is on family therapy for depressed and suicidal youth. I spoke with two of the three developers of Attachment-Based Family Therapy, Guy Diamond and Suzanne Levy. The third developer, Gary Diamond (no relationship to Guy Diamond) lives in Israel and was not available for the interview.

In 1996 I got my first post-MSW job as a crisis worker for children and adolescents. Our job was to assess youth for suicide risk, coordinate with schools, juvenile detention facilities, emergency shelters, residential treatment facilities and hospital, and provide what we called short-term stabilization therapy. We’d have 30 days to work with the kids, parents, and the family to reduce suicide risk and set them up for longer-term treatment. It was assumed that we’d do family therapy. No, we assumed that working with the family was an essential part of reducing suicide risk and getting the youth and family back to their pre-crisis functioning. Despite the excellent supervision and on-the-job training I received, we were all just flying by the seat of our pants.

In 1996 there were no published research studies on how to best work with suicidal youth. There wasn’t really much research on what was effective for depressed youth. David Brent’s now classic study comparing cognitive behavioral therapy, family therapy, and supportive therapy for depressed teens wasn’t published until 1997. I didn’t realize this at the time. I kept asking, “how do we best work with suicidal youth and their families?” I would get answers like, “if it seems like the parents aren’t so strong, use structural family therapy,” or “if the kid seems suicidal because the family doesn’t want to deal with their problems, take a strategic approach.” Mostly we would put out one fire at a time. It wasn’t until years later that I realized that we relied on clinical wisdom because that’s all there was.

I share this with you for two reasons: First, many of you listening are working with populations and problems for which there is mostly clinical wisdom. If you don’t if that’s true, then look it up. Find out if there are empirically-supported interventions for the populations, problems, and settings in which you work. Second, you can imagine how excited I was in 2008 – 12 years after my first job as a crisis worker - when I found out that someone had developed a family-based intervention for suicidal youth. David Brent, the guy I mentioned a few minutes ago that did the 1997 study, told me that Guy Diamond in Philadelphia was doing research on families and suicidal youth. Fast forward to 2012 and I learned that Guy was starting a 5-year clinical trial comparing ABFT to… wait for it… a version of the supportive therapy David Brent developed for his classic 1997 study.

I was very excited to do an episode on ABFT for several reasons:

  • First, anyone who works with suicidal youth needs to consider the family system. 
  • Second, although there are several empirically supported family therapies out there, such as Jim Alexander's Functional Family Therapy, Howard Liddle's Multidimensional Family Therapy, Scott Henggler's Multisystemic Therapy, Jose Szapocznik's Brief Strategic Family Therapy, they mostly been evaluated with youth with substance use and / or juvenile justice involvement. ABFT’s focus on depression and suicide risk is a unique contribution to the family therapy universe. 
  • Third, in social work education and practice there is a lot of talk about empirically supported treatments. I wanted to talk to the folks who are on the front lines of developing and testing an empirically supported treatment. 

And something that isn’t in the interview, but that speaks to social work’s sense of social and economic justice is that every time there is a large funded clinical psychotherapy trial, people have access to some of the best therapy in the world - for free. So, participants in the ABFT study receive top-notch supervised therapy for 16 weeks, and are followed by a research team for a total of a year. So, even if you don’t fully buy into empirically-supported treatments, there is a real value to the community for having access to the kind of treatments that are only available during a clinical trial.

In today's episode, I spoke with Guy Diamond and Suzanne Levy at the Center for Family Intervention Science at Drexel University in Philadelphia, PA. I was grateful to be able to schedule a time with Dr. Diamond and Dr. Levy because they are currently in the middle of a five-year NIMH clinical trial comparing ABFT to a non-directive supportive therapy.  In fact, we spoke in one of the therapy rooms where participants receive either the experimental condition - ABFT, or the control condition - non-directive supportive therapy. If you listen closely you can hear the project staff opening and closing doors, walking up and down the halls, etc.

ABFT is the only family-based psychotherapy with empirical support for reducing suicidal ideation in youth. ABFT is listed on the National Registry of Evidence-based Programs and Practices, also referred to as NREPP. According to NREPP, 

"Attachment-Based Family Therapy (ABFT) is a treatment for adolescents ages 12-18 that is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. The model is based on an interpersonal theory of depression, which proposes that the quality of family relationships may precipitate, exacerbate, or prevent depression and suicidal ideation. In this model, ruptures in family relationships, such as those due to abandonment, neglect, or abuse or a harsh and negative parenting environment, influence the development of adolescent depression. Families with these attachment ruptures lack the normative secure base and safe haven context needed for an adolescent's healthy development, including the development of emotion regulation and problem-solving skills. These adolescents may experience depression resulting from the attachment ruptures themselves or from their inability to turn to the family for support in the face of trauma outside the home. ABFT aims to strengthen or repair parent-adolescent attachment bonds and improve family communication. As the normative secure base is restored, parents become a resource to help the adolescent cope with stress, experience competency, and explore autonomy. 
ABFT is typically delivered in 60- to 90-minute sessions conducted weekly for 12-16 weeks. Treatment follows a semistructured protocol consisting of five sequential therapy tasks, each of which has clearly outlined processes and goals:
  1. Task 1: The Relational Reframe Task, with the adolescent and parents (or parent) together, sets the foundation of the therapy. After an assessment of the history and nature of the depression, the therapist focuses on relational ruptures. This shift pivots on the therapeutic question, "When you feel so depressed or suicidal, why don't you go to your parents for help?" The progression of this conversation leads parents and the adolescent to agree that improving the quality of their relationship would be a good starting point for treatment.
  2. Task 2: The Adolescent Alliance Task, with the adolescent alone, identifies relational ruptures in the family and links them to the depression. The adolescent is encouraged and prepared to discuss these often avoided feelings and memories with his or her parents.
  3. Task 3: The Parent Alliance Task, with the parents alone, explores their current stressors and their own history of attachment disappointments. These conversations activate parental caregiving instincts to behaviorally and emotionally protect their child, which helps motivate parents to learn and use new attachment-promoting parenting skills.
  4. Task 4: The Attachment Task, with the adolescent and parents together, creates an opportunity for the adolescent to directly express his or her thoughts and feelings about past and current relational injustices. Rather than defending themselves, parents help the adolescent fully express and explore these emotionally charged topics. This conversation helps the adolescent work through trauma, address negative patterns in the relationship, and practice new conflict resolution and emotion regulation skills.
  5. Task 5: The Autonomy Task, with the adolescent and parents together, helps consolidate the new secure base. In solving day-to-day problems, parents provide support and expectations and the adolescent seeks to develop autonomy while remaining appropriately attached to his or her parents." (http://legacy.nreppadmin.net/ViewIntervention.aspx?id=314)
If you're interested in learning more about ABFT, you can buy the treatment manual Attachment Based Family Therapy for Depressed Adolescents, watch a free webinars http://drexel.edu/familyintervention/abft-training-program/webinars/, or attend a 3-day workshop April 22-24 in Philadelphia.  More information and registration can be found here: https://www.drexel.edu/cnhp/academics/continuing-education/Health-Professions-CE-Programs/ABFT/. And now, without further ado, on to episode 96 of the Social Work Podcast: Attachment-Based Family Therapy for Depressed and Suicidal Youth: Interview with Guy Diamond and Suzanne Levy. 

References


  1. Feder, M. & Diamond, G.M. (in press). Parent-therapist alliance and parent attachment promoting behaviors in attachment-based family therapy for suicidal and depressed adolescents.  Journal of Family Therapy.
  2. Diamond, G.S., Diamond, G.M., & Levy, S.A. (2014) Attachment Based Family Therapy for Depressed Adolescents. Washington D.C: American Psychological Association.
  3. Diamond, G.M. (2014). Attachment-based family therapy interventions. Psychotherapy, 51, 15-19.
  4. Diamond, G.M., & Shpigel, M. (2014). Attachment-based family therapy for lesbian and gay young adults and their persistently non-accepting parents. Professional Psychology: Research and Practice, 45, 258-268.
  5. Krauthamer Ewing, E. S., Levy, S. A., Boamah-Wiafe, L., Kobak, R., Diamond, G. (2014). Attachment-based family therapy with a 13-year-old girl presenting with high risk for suicide. Journal of Marital and Family Therapy. doi: 10.1111/jmft.12102
  6. Diamond, G.M., Diamond, G.S., Levy, S., Closs, C., Ladipo, T., & Siqueland, L. (2012). Attachment-based family therapy for suicidal lesbian, gay and bisexual adolescents: A treatment development study and open trial with preliminary findings. Psychotherapy, 49, 62-71.
  7. Diamond, G.S., Creed, T., Gillham, J., Gallop, R., & Hamilton, J. L. (2012). Sexual trauma history does not moderate treatment outcome in Attachment-Based Family Therapy (ABFT) for adolescents with suicide ideation. Journal of Family Psychology, 26, 595. 
  8. Higgins, J., Friedlander, M., Escudero, V., & Diamond, G.M. (2012). Engaging reluctant adolescents in family therapy: An exploratory change process study. American Journal of Family Therapy, 34, 24-52.
  9. Diamond, G.S., Wintersteen, M.B., Brown, G.K., Diamond, G.M., Gallop, R., Shelef, K.& Levy, S.A. (2010). Attachment-based family therapy for suicidal adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49,122-131. 

Resources




APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2015, March 10). #96 - Attachment-based family therapy (ABFT) for depressed and suicidal youth: Interview with Guy Diamond, Ph.D., and Suzanne Levy, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from  http://www.socialworkpodcast.com/2015/03/ABFT.html

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