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: https://abftinternational.com/)
"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:
- 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.
- 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.
- 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.
- 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.
- 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
Transcript
IntroductionToday’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.
"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: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.
- 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.
- 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.
- 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.
- 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.
- 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)
10:38 Jonathan Singer: Alright Guy and Suzy, thanks so much for being here on the podcast talking about attachment based family therapy. So Guy attachment based therapy the only treatment that has empirical support for reducing suicidal ideation. It’s a family therapy and it has an attachment focus, could you talk about why that seems to work.
11:0 Guy S. Diamond: So lets think a little about why family therapy for suicidal teens are thinking is sometimes families are chaotic and difficult and people are struggling with things which may contribute to teens feeling suicidal. And sometimes teens are troubled or experiencing bullying or questioning their sexuality and having a lot of inner turmoil, depression, and this can be extremely destabilizing for families. So even the best families when faced with a kid who is struggling with suicide can be pretty disrupted and under a lot of stress, for us to approach this population and with family in mind it allows us to improve the context of the adolescents life if the family is a problem for that adolescent we want to try to tinker with it if the family has been overwhelmed and unavailable to provide the support that the adolescent needs, we want to try to tinker with it. And our experience is trying to effect the context of an adolescent’s life, helps reduce some of the stress, reduces some of the difficulties that get in the way of the adolescent using the parents for comfort, security, and protection. And this is sort of what leads us to an attachment framework, a lot of the old theoretical of cybernetics or general systems theory, even some of the narrative therapy models for me don’t provide a language and a theoretical frame work for what am I doing in the room, what am I trying to facilitate, what am I trying to build on. I think attachment theory also comes at a developmental psychology and really has a deeper both empirical and clinical understanding of the role that the family context plays in facilitating adolescent development, child development, and I think that is a very potent set of ideas for family therapists to be thinking about in many ways what we are tying to do is recalibrate a family to be the cauldron, the context, where kids can grow up and learn to trust themselves and learn how to manage their emotions and learn how to trust other people and learn how to feel worthy of being loved and capable of loving and it all happens in the context of the family. In that regard I think our model as you will hear from myself and Suzanne, its a very strength based model, its about helping parents be empowered, to provide the kind of context we know is needed for healthy child development. So its not a blame a parent its not you did something wrong, its that we can help you resuscitate some of the skills and capacity, patience to help these kids that it will create the greatest opportunity for kids to grow and settle in and become what they are capable of being. So attachment theory provides a lot of that frame work, its a lot about parental sensitivity, for a balance of structure and love, its a lot about kids emotional development and regulation and there ability to trust in the world and we are tying to repair some of that so that a child can really have secure attachment base and parents can provide the intimate and protective parenting structure that we think is healthy for kids.
14:43 Jonathan Singer: You know a lot of the families that I’ve worked with, I know that a lot of folk out in the field that the parents desperately want to be doing the right thing and it sounds like you are offering a way for parent to either think about what’s going on with their kids or to be with their kids in a way that they can do what they want to do but for whatever reason they cant. And I know that there is five tasks for ABFT, could you talk about what happens in the first task?
15:15 Guy S. Diamond: Yea, let me just say something about the tasks in general and then get a little bit of the content of them. So again a theoretical and empirical framework about child and family development guides us. We use these ideas to organize what we think should be happening in a family and what it takes particularly for a lot of kids with trauma, kind of optimal family context it takes to help a kid move through and resolve some trauma experiences. And then in that regard the model provides a lot of guidance and structure to, its a very a depth oriented emotion focused experiential process in the room, but for the therapist there’s a clear framework of what am I focused on, what am I trying to accomplish and what are some of the steps I can do to get there, and because of that the therapist has a much higher level of intentionality then what happens in some models and that allows them to get to some pretty profound primary emotional interpersonal processes fairly rapidly in the treatment. So by ten weeks were clearly in to the middle of some of the biggest themes that drive some of the pain in this family partly because of the five tasks that allows us to get there. So what are the tasks? It really is a stage specific model, its not overly rigid, its not a prescriptive recipe if people deviate or find different things or have to go down a different road for awhile, that’s you know permissible. There is a treatment manual, but it’s a fairly flexible and principal manual. So for us the tasks organized what we think are critical steps of therapy and for our work and maybe for any family therapist, really initial model of the therapy is getting the family to buy into doing family therapy. You know why am I here, my kid has got the problem, I will sit in the waiting room, and I think all of us as family therapists have to help the family understand why the parent need to be in the room, what’s there role, what’s there potential contribution, and for us we know that’s a critical challenge to get negotiated. So we take it on very intently in the first session and try to make it the focus of our work. So for us the primary goal of the first session is what we call the relational reframe, and it’s really, it’s not about reframing the problem, it’s about reframing the goals of the therapy. You come here, you want us to fix your kid, and we want you here because we think if we can help the family improve that the kid will have a much better chance at improving as well. We are trying to win them over to a more to a more systemic family frame on what therapy will look like at least as the initial phase of therapy. And for us it has to do with again from an attachment point of view rebuilding trust. Why doesn’t your son come to you when he is up in his room feeling suicidal, what’s gotten in the way of him seeing you as his natural, instinctual, context for safety and protection. And we want to try to figure out what kinds of things have ruptured that trust, have gotten in the way of that trust, so that we can try to resolve those things so that once again your son can see you as someone whose trustworthy, that they can turn into, that they expect the parent will be there and the next time will feel suicidal I am going to you instead of taking pills.
19:15 Jonathan Singer: So Suzy what are some of examples of ruptures?
19:18 Suzanne Levy: We can think about ruptures in a few different ways. They can be small like attachment injury or they can be larger like traumas and so when we talk about attachment ruptures, we usually talk about little ts and big ts. So like something that a little t can be is just feeling like you know go to talk to your parent and they just don’t get you, they don’t understand, they can consistently ask why and don’t really get it or they criticize you go to them, or disagree with you maybe in completely invalidate what your saying so that might be a little t. A bigger t would obviously be like things like parents own psychopathology, you have a parent who is depressed, using substances and so that makes them unavailable to you when you try to go to them, mom’s depressed she is going through her own stuff I cant burden her, put more on her or its just going to make her sadder. And then we have our larger ts, which are you what you would really consider traumas. So abuse, whether it be physical, emotional, sexual abuse, neglect, abandonment and so we certainly have families in which you know maybe the family still is somewhat intact but emotionally the kid has felt abandoned or something has happened that every time they do something wrong there shift off to another relative house and not kept part of that primary family.
20:43 Jonathan Singer: It makes a lot of sense that those would be you the ruptures the things that would keep the kid from going to the parents, is that what you guys do in task one, like you figure out all of those and if you do how does that then make the parents and the kids want to keep working together on this issue?
21:7 Suzanne Levy: Yeah it’s a big question to ask, so we don’t necessarily get to all of them in task one. Really what were trying to do in task one is to establish the fact that this adolescent isn’t going to their parent for help and so we find often in task one, maybe those little ts will come out. Oh I feel like my parent doesn’t understand me, they just don’t get it or I feel uncomfortable going to them. And really in task one were not looking to solve any of these ruptures if some of them come out great and were just trying to establish this kid isn’t going to their parent and that is having dire consequences for everybody in the family. And we use that to help motivate the family and say we want to work on our relationship and we want to figure out why our child isn’t coming to us for help and support when they are feeling horrible.
21:54 Jonathan Singer: So after everybody on board with this idea that they should be there as a family, what’s the rational behind saying hey you guys need to be here as a family and working with individuals in the second and third task?
22:9 Guy S. Diamond: That’s a good question, so many people who have studied family therapy have seen the old mention tapes and you know they are training tape so they are a little contrived context but essentially the old structural model use to be turn to each other and do something different. The enactment we believe we think the enactment, the experiential event in the room of being different with each other is an important therapeutic action. The problems with the old models is that you would say okay Johnny turn to your mom and tell them how you feel and Johnny doesn’t know much more about how he feels, he hasn’t articulated that feeling, he doesn’t feel safe about it, he doesn’t feel the therapist on his side, your going to have him start talking, the mom is not prepared, he’s going to do the same old thing he usually does and criticize or get defensive and so we in our model think a lot about preparation. And take a lot of time meeting alone with the kid in task two and then alone with the parent in task three and then a very thoughtful tempered think through all the things that we think we need to do in order to get them ready to have a different kind of conversation. So in task two I mean the essence of it is to help the child be able to more deeply and honestly and emotionally articulate some of the kinds of ruptures that have gotten in the way of trusting their parents. We think a lot of kids know what these things are but usually they express them through temper tantrums or behavior problems and they never come out directly at out of the box and say look mom this is what hurt my feelings or bothers me when you do this. And were not trying to encourage to blame the parent but were trying to coach them to be more articulate, more direct, more honest, to feel in entitled that they can express their concerns about hurts and injustices that they felt. So that’s really the goal of task two and help the kid understand his attachment ruptures as we talk about it and then get them to be willing to talk to their parents about it in the future in task four.
24:32 Jonathan Singer: So what specifically happens in task two?
24:36 Suzanne Levy: Well first obviously we want to really get to know the adolescent and join with them we want to have them see us as somebody who is there to be supportive and caring and who is going to really listen to their story. Because we that for a lot of these adolescents there not even sure of their own story, and they certainly haven’t had anyone that listened to it in a supportive way. So we do kind of the normal things of joining being with, understanding who they are, what they like, were also taking note of what the defenses that they have and not necessarily naming them in this moment but were going to bring them up later on and then just trying to explore their worlds a little bit more, who there friends are, what their relationships been like, how school going. And then we also really want to get a better picture of their depression or suicide narrative and really understand kind of what is causing there distress, how long has this been going on, what are they think about it, what does it mean for them, and what are the ways in which effects them, so how is it impacting their life on a day to day basis. And once we have that, we also might then be pointing out places they might have defenses, might notice that they shut down as soon as they start talking about something emotional, they completely shut down, or there kid starts talking about something emotional, they get completely deregulated, and cant contain themselves and so working with those defenses helping them take note of that, and then what we try to do is try to understand so all of these horrible things are going on in their life, their depressed, their having thoughts about suicide, but we know they are not reaching out to their parents and that reaching out to their parents takes trust. And so we kind of revisit those ruptures that we might have tapped into a little bit in task one and now we want to fully get the attachment narrative so we want to understand all of the ways in which the relationship has unfolded with their parents. So what are the times that they really needed their caregiver and their caregiver failed to be there for them in a way that was helpful. And were going to try to get a different episodic memory and really understand what that meant for the adolescent, how they felt at that time, how that’s effected them, we bring in attachment themes, so common themes we hear are abandonment, neglect, rejection, feeling uncared for, and really try to help the adolescent make a more coherent story about what’s happened to them and their relationship with their parent. And how that’s affected more broadly and then we tie that back to the depression and suicide and we use that as a motivator to get them to want to talk to their parents about these things. And so you know like I said in the beginning sometimes for these kids their parents are the direct cause of their depression or one of the reasons that they are depressed, they fight all time, or parents have done things in the past that has been really upsetting but other times its not its these kids are depressed for reasons that are unrelated to their parents but they are unable to talk to them because they feel liked their parent criticizes them or judges them. And so were tying these pieces together and then helping the adolescent see that the way to move past that depression and suicide feeling is to repair that relationship with their parent and the benefits of doing that for them.
27:49 Jonathan Singer: So what happens in task three when you’re meeting with the parents?
27:53 Guy S. Diamond: The goal with the parents is a complicated one I think we all who work with families know that parents bring a lot of history, a lot of their own challenges, marital problems, depression, a lot of parents are great and committed and just lost and don’t know what to do, I mean there is a whole range of what we get. The ultimate goal is to activate and enhance their care giving instinct, the part of them that does care about their kid that wants to help their kid. Many of our parents feel that way coming in, given how much you love your kid, how much you want to be for them, it must break your heart, that he doesn’t come to you when he is in trouble. And we try to activate the acknowledgment in parents that as much as I love my kid, and mean well about my kid something not working and I am not being able to be the kind parent for that I want to be and having my kid come to me in ways that I want. And if we can sort have activate that decider in parents to want to be more of an available. We then can actually coach them on some very particular skills we think are important, that would allow the kid to turn to the mom more and trust them more. In that regard were trying to prepare for the attachment test we know the kid is going to come to the table and sort of get these things off their chest and we want the parent, its a tall order its a high bar for parents but we want them to be able to listen not defend, not criticize, but really focus on the child and the help the child tell their story. So we sort of sell it to parents, as you know part of the reason they turn to suicide is because they are so internally confused, that they turn to self-harm instead of being able to articulate the things that have bothered them. If you could be there and provide a being sort of of a witness and be able to be available and help them articulate these things, it’s actually a learning experience for the kid. This is a new way that you could help him learn about himself, articulate feelings and speak up for himself and seek help in ways that are productive then self harm.
30:12 Jonathan Singer: So this task with the parents is really like I recognize your a lot of stress, its difficult having a suicidal kid, their financial pressures and that’s really how you break down their, like their defenses, and build report and relationship with them right?
30:29 Suzanne Levy: Yeah that’s one of the ways that we do that another thing that for us is really important in ABFT is looking at parents own inner generational history of attachment. So were not necessarily going to go and do their entire history and do huge genogram. But we really take usual about a session maybe not always an entire session but were looking to see parents own experiences of being taken care of by their caregiver. And what we find often is were going in to listen for parents own history, findings moments when they needed their parent, when their there attachment instinct was activated and looking to see how their caregiver responded and how that effected them. And what we find in going to these stories with parents that there stories are really similar to their adolescent’s stories. That I mentioned earlier that when we were talking about task one and some ruptures that you could have. I work with an adolescent whose rupture was every time her and her mom got into a fight and mom shipped her off to grandma’s house. This girl really felt abandoned by her mom and what we found by going into mom’s story that mom had several instances of being abandoned when she was younger, her mom kind of took her step fathers word over sexual abuse and kicked her out of the house, her father abandoned her and wouldn’t let her into his house, she went to a group home, and the care takers there abandoned her and so just time and time again this theme of abandonment, while this looks drastically different from her daughter’s experience, feelings were the same. And so just like we do with current stressors, try to stay with the parents story and really hear their story and emphasize with them and validate their experience and have them feel taken care of. And we want the parents to resonate with their own story and emotionally and feel some empathy for themselves and once they done that and once you see this emotional connection to this own story. Then we help parents think about how is their story similar to what their adolescent may be experiencing.
32:33 Jonathan Singer: So interesting that because one of the experiences that service providers run across is sort of these cycles, right? There might be the cycle of poverty, or cycle of abuse or cycle of addiction or some sort of thing. And what your saying is that you hear something from the kid, then you hear from the parent, but what do you say to get the parent to realize oh I’m doing to my kid what my parent did to me?
33:0 Suzanne Levy: So I think you have to kind of coach what’s appropriate. So in this example of abandonment you know I was really able to say to the parent you know you have had all these experiences of being abandoned and throughout moms story I was weaving in the word abandonment and that really resonated with mom. And talking about how this impacted this mom and how despite all of this abandonment mom is able to move on in her life and was in school, getting a degree and then just brining in the adolescent and saying I wonder you know I know you and your daughter have a lot of conflict sometimes and that when this conflict happens that you take her to grandmas house to take care of until things cool down. And I wonder you I know its such a different scale but I wonder in those moments that you take your daughter to grandmas house, I wonder in those moments that she feels abandoned like you did even though the scenarios are so different and your not really abandoning her I wonder in those moments if it feels like abdomen to your daughter. And so really kind of pointing, we recognized these situations are really different but the emotionality underneath might be the same.
34:13 Jonathan Singer: I can see how the that being incredibly powerful for a parent especially the way you said it wasn’t blaming, wasn’t judging, it was do you think its possible that your daughter might be feeling the same way even though you don’t mean it that way?
34:26 Suzanne Levy: Yeah, it’s the difference between intention and effect right? I mean mom’s intention is to take care of the child in that moment and provide safety but the effect is the exact opposite. That what the girl feels is that mom isn’t protecting, I can’t trust her with my feelings, and she can’t handle me.
34:45 Guy S. Diamond: A lot of the work is us connecting with parents so they trust us more the most common path way is you had no body to turn to when you were a kid. How would you like to be able to be that for your child now? So we try to use some intergenerational history and understanding to activate their parental instinct, their caregiving instinct, we then teach them some skills about active listing that are emotional focus parenting skills. And then when we sort of feel confident enough both in the session, alone with the child and alone with the parent we feel that its good enough, its not always perfect but sometimes its good enough we say okay were going to head into task four and try to really slug through some of these core attachment traumas that have happened in this family.
35:34 Jonathan Singer: So it’s really been so much preparation leading up to task four. What happens in task four? It sounds pretty important.
35:45 Guy S. Diamond: Yeah, so you know we go back and forth ourselves how therapeutic is task two and three in of itself or is it really just preparation for task four and that varies case by case. Sometimes you do some pretty profound work with parents or kids alone in task but you’re always in your mind thinking how is this going to help me get ready for the conversation I want them to have. We really coming at a structural family therapy believe in an enactment, we believe in experiential change that people in the room could have an experience of each other a more positive experience that could actually affect the way they think about themselves. So what we want is the kid to start a therapy saying my mom wont listen to me, she doesn’t care how I feel, I cant talk about myself, comes into this experience, and comes out feeling like oh my god my mom was really there for me and could really listen and I didn’t have a temper tantrum, you know maybe I could expect she will be there for me and maybe I can articulate things that are on my mind. So that’s our goal of the task, the overall structure is mom and dad say look there’s been a lot that’s gone on in our family and sometimes we have heard how you feel about enough, todays the day were here, ready to listen, we want to know what’s going on, whatever you want to say, we want to hear your thoughts and that creates a little bit of safety and context. And ideal what happens is the kid starts to talk and basically says alright you know look there has been some things that have been upset me when you two divorced and I felt like I was stuck in the middle of it when you two you know when mom went to the hospital and I didn’t know why and no one explained it and when I was being bullied in school and nobody protected me and the child begins to tell these often quite profound stories of danger, of feeling threatened of, feeling abandoned, feeling alone, feeling sad. And they learn how to put all these feelings in to words, they learn that they can tell these stories more coherently and ideally what happens is the parents provide the optimal parental environment of love and protection and safety and we really think about this as a corrective attachment experience. The attachment framework is really when a child is young and feels threatened, the attachment is I need help, I need comfort and at that behavioral system gets activated and they go seeking there parent and grab on to moms dress or climb in dads lap and seek out comfort. And these episodes for us are sort of a reenactment of that, that the kid finally comes to the table and says look I know I have been acting mad and throwing things and but the truth is I am really sad and I am really upset and I feel confused and I feel lost and parents provide a lap and say come here Johnny, tell me how you feel were going to be here for you. So that this attachment rupture conversation gives the child a chance to turn to their parents again and find out their trust worthy and gives the parents a chance to be the kind of parent that the kid really felt they needed during these times of high threat, high emotional need. The conversation goes on, it can be quite complex, it can last for multiple sessions, there may be multiple topics to talk about, but the goal it is sort of of a honest, emotional encounter with each other, were people feel safe to tell the truth, and feel able to better understand the stories of their lives without feeling afraid or overprotective and threatened. It defiantly tends to towards helping the child talk about their side, were not their to have mom talk about her depression to much or her alcohol problem or the martial violence there might be some of that, some of these kids know a lot about it but never heard about it. We know kids who grown up with bipolar parents and have been victim of a lot of chaos because of that and no one has ever told them moms bipolar and given them some framework of how to understand that, what does that mean and no its not me. So there is an element of this were parents might tell some of their story and help the kid understand it but its really the focus, the goal is helping the suicidal kid find a better way to put the story of their life together and start to feel like I can turn to my parents, they can listen to me, I can expect them, to be available when I needed them.
40:45 Jonathan Singer: So this sounds like a really lofty goal, I mean repairing attachment ruptures how do you do that?
40:53 Suzanne Levy: So this really comes off of what we done in task two and three, we’ve worked hard to prepare both the parents and kids to come to talk about these issues, but we know its going to be difficult. Even if you do all the prep work in the world but these families are use to talking to one another in a certain way. We’ve talked to the adolescent and the parent about what are they worried it’s going to happen and this session. What are their fears, we’ve prepared around how to make sure that the fears that they do have how do we protect them, and the adolescent is ready they know what they are going to talk about because we have prepared them. And we really start them out by having the adolescent turn to the parent and start talking why it’s difficult to them to go the parent. As the therapist I’m looking to see how is each person reacting and I’m in it with them, I’m going to let conversation go on when its going well, but I’m also really making an attempt to make this conversation go different. So I’m going to be working hard to coach both the parent and the adolescent to make this that corrective attachment experience if the kid is having difficulty articulating what there thinking, feeling, I know what it is because we have already talked about it in task two. So I am going to prompt them or get the parent to ask questions that would prompt them by coaching the parents, if the parents if there immediate reaction is to get defensive and fall back into that normal style that the kid is afraid of I’m going to address the parents and help realign them and remind them of the things we talked about in task three or their own attachment history to get them in the right emotional space. I might prompt them the type of questions they should ask and this whole time I am having this conservation go between the parents and kid, I want to be out of it, I don’t want them talking to me because that is going to decrease emotionality. So I am working hard to make sure the conversation going well but still between the parent and adolescent. So you might in family that is going to struggle more do a lot of coaching, the kid coaching the parent, to get this to be a really corrective attachment experience.
42:53 Jonathan Singer: So tasks one, two, and three you know lead up to this conversation which you describe as a corrective attachment experience so assuming that this works and the kid feels comfortable or secure in the knowledge that I can go to my parents, you have a fifth task so like what’s left to do after the secure base has been reestablished like what do you do in task five?
43:22 Guy S. Diamond: So that’s a great question and you know the way we think about the progression is we know from today's developmental research that kids who feel both connected feel attached their parents but also can go negotiate and explore autonomy are the most healthy well adjusted kids. The balance of attachment and autonomy is the formula for healthy adolescent development not separation and individuation or storm and stress and those models are not how we think about adolescents anymore. So for us we feel like out first goal of task one, two, three, four is to reestablish, recalibrate, repair, refurbish the attachment security, so that can once again be in place. And you know we accomplish what we can, we try to be realistic, and we do have profound conversations where people really make shifts in how they view each other and their relationships. But with that foundation set we now think about okay we now have secure attachment now we have to help promote autonomy and the goal is with the secure base in place. So the family can once again be a cauldron to promote, challenging, courage support, the adolescent in starting to grow up, getting back to school, getting a job, going out with friends again, some of its functional things, sometimes there’s then discussion related to identity development that can occur, a lot of the teens we work with are sort of questioning their sexuality and once there’s enough attachment security we find a lot of these teens want to use their family as a place to explore this and understand it or at least support from it so there might be questions like that. We talk sometimes about racism, ethnicity, and how do those things impact who I am and who I’m going to be and the child has a place to turn to explore things about themselves, experience in the world and the family continues to provide a secure base that will allow the foundation so they can do exploration. So task five is really about helping the child reengage in their life a lot of out suicidal, depressed teens have fallen off the wagon, they are not in school, they have lost friends, they have been in and out of hospitals, and so were reconstructing a life for them and task five begins to focus on that. There’s sometimes not a clean boundary between task four and five and we go back and forth. We got to pick up a few themes but we are thinking in this relatively brief therapy you know its before were done I want to make sure he is back in school, you know feeling that mom and dad have worked out more reasonable expectation of chores and duties and restrictions and curfew and that we sort of work on normative adolescent things. And that the all think about this is goal corrected partnership that a parent and an adolescent. Its not that the child is an infant and the parent has to take care of them now the child has a voice and should have input in negotiating how things go for their life. Not that they are in charge we don’t want parents to think that but they need to be more of a participant at the table if they are going to feel that there independence emerging adulthood is being honored and certainly as a kid gets older that becomes even more important. So we help the families sort of renegotiate some of the daily living in life.
47:21 Jonathan Singer: So Guy the way that you are describing task five is what I think of as family therapy, like if I were to describe family therapy is in a general sense I would describe what you just described as task five.
47:34 Suzanne Levy: And that’s how we think about it also. I mean when we give our workshops we talk about the fact that task five is going look like more general family therapy. The difference thought is that it’s built on this now having repaired these injuries between the adolescent and parent. That for a lot of these topics you talk about in task five if there isn’t trust and a feeling of safety, kids aren’t going to open up to their parents about these issues. So we really look at you need to have task four for repairing that trust and safety and protection in order to do task five.
48:8 Jonathan Singer: What’s an example of that?
48:10 Suzanne Levy: So an example of being, I worked with a client who was gay, it was known in the family that he was gay. And the parents on the one hand would say they were really excepting of that but then they would do these things that we call microaggressions. For example the kid would come downstairs in tight jeans and the parents would say things like are you really going to wear that outside cause that kind of makes you look like you are gay, but give minutes before they were saying we don’t care who you are, or who your attracted to it doesn’t matter to us so these are conflicting behaviors. So for this adolescent that was a really big rupture for this kid, that was one of the things he wanted to talk to his dad about in task four of you say these things on the one hand that you are okay with me but you do these things that show me your not and how can I trust you because you are inconsistent. And so we really needed to talk about that in task four so then we could talk about issues that he was struggling with around being gay in task five. So this was a kid who was deeply religious and he was struggling with the fact that he was gay and his religion says that not okay. And how do you kind of being those two things together and he could never have trusted in his father to discuss that with his dad prior to having this conversation in task four about the microaggressions because it wouldn’t have been safe but now that they have worked through those issues and dad didn’t even realize he was doing those things, they were able to talk about it and trust has been repaired. He was able to have these really deep conversations with his dad in task five about there religion, about him being gay and how do you still be who you are and still be religious and bring those things closer together.
49:52 Jonathan Singer: Guy and Suzy thank you so much for being here on the podcast and for talking about attachment based family therapy.
49:58 Suzanne Levy: Thank you for having us here.
50:0 Guy S. Diamond: Yeah, thanks Jonathan. Really great to be here, we love your work so I am honored to be on your show.
References
- 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.
- Diamond, G.S., Diamond, G.M., & Levy, S.A. (2014) Attachment Based Family Therapy for Depressed Adolescents. Washington D.C: American Psychological Association.
- Diamond, G.M. (2014). Attachment-based family therapy interventions. Psychotherapy, 51, 15-19.
- 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.
- 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
- 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.
- 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.
- 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.
- 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
- ABFT Webinars: http://drexel.edu/familyintervention/abft-training-program/webinars/
- Facebook page: www.facebook.com/Attachment.Based.Family.Therapy
- Twitter: @ABFTtraining
- ABFT on NREPP: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=314
- ABFT on Promising Practices Network: http://www.promisingpractices.net/program.asp?programid=274
- Gary Diamond, Professor and Chair of the Department of Psychology, Ben Gurion University, Israel: http://www.bgupsychotherapyresearch.org/
- Upcoming Workshops
- April 9th, 2015 – Bentley Conference Center, Boston MA – registration: https://afsp.wufoo.com/forms/mqhhnp711wr1b9/, For more information contact Kerry Lassaux at KLassaux@afsp.org
- 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/
- May 15, 2015 – Hotel Phillips, Kansas City MO – registration: https://afsp.wufoo.com/forms/mqhhnp711wr1b9/ , For more information contact Barb Nelson at barbnelson@afspkc.com
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
3 comments:
I learned a lot from your Podcast. I'm a student with limited knowledge of Attachment Theory, but, wow, this made me rethink many of my past beliefs. This sounds so encouraging. Have you compiled any statistics on the effectiveness of this theory? For example, it is somewhat effective ___% of the time. Thanks again.
Stephen,
I'm just seeing your comment now. We have a lot of research on ABFT. For a review of the research on ABFT, visit https://onlinelibrary.wiley.com/doi/epdf/10.1111/famp.12241. You can also visit our webpage for more information www.abfttraining.com or www.drexel.edu/abft. Please feel free to email me at slevy@drexel.edu.
Suzanne Levy
Stephen - i'm so sorry, I'm just now seeing this comment. We indeed have much research on the effectiveness of ABFT as well as what processes within ABFT lead to change. We have our publications listed on our website www.abfttraining.com. We also recently published a summary of our research. You can find it here: https://onlinelibrary.wiley.com/doi/full/10.1111/famp.12241
Suzanne Levy
sal89@drexel.edu
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