ATTACHMENT BASED FAMILY THERAPY Gary M Diamond Ph

ATTACHMENT BASED FAMILY THERAPY Gary M. Diamond, Ph. D. Associate Professor Ben-Gurion University of the Negev

Overview n n n Brief, focused treatment (12 to 16 sessions) designed specifically for treating depressed and/or suicidal adolescents Empirically informed and supported Manual is principally/task driven, focused, detailed but flexible Built around 5 distinct, yet interrelated treatment “tasks” Based in attachment theory and Structural Family Therapy

Overview Center for Family Intervention Research, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine n Guy S. Diamond, Ph. D n Gary M. Diamond, Ph. D. n Suzanne Levy, Ph. D. n Lynne Siqueland, Ph. D. n

Theoretical and empirical basis of the treatment

Normative Adolescent Development and Developmental Psychopathology Past models of normative adolescent development (Storm and n n Stress) (Blos, et al. ) Current, empirically-based description of normative adolescentparent relations (Steinberg, L. ) n Shared values, respect and admire parents n Parental admiration, validation, care and protection still important n Increased sharing with and investment in peer group but connection maintained around important issues (life decisions, crises, etc. ) n Increased bickering about daily tasks (curfew, clothing, friends), but does not threaten cohesion and bond n Less than 25% of teens report ongoing conflict, 80% of whom report it started in childhood (In other words, high conflict is not the norm)

Not only is high adolescent-parent conflict, parental rejection, criticism and neglect normal, but such processes place adolescents at a higher risk for both depression and suicidal ideation. n How? n

Mechanisms linking negative adolescentparent processes and adolescent depression/suicide n n n Negative parental behaviors, such as criticism, rejection and abuse are both directly and directly linked to adolescent depression and suicide. They are DIRECTLY linked because parental criticism, abuse and neglect makes kids feel bad about themselves. When parents tell or make their children feel like something is wrong with them , that they are a burden, adolescent’s internalize these messages. They begin to feel worthless, like failures, helpless, hopeless and alone. Self-esteem decreases, selfefficacy decreases. Such perceptions of themselves and experiences are

Mechanisms linking negative adolescentparent processes and adolescent depression/suicide n n n They are also INDIRECTLY linked to depression and suicide via the quality of the attachment relationship. More specifically, when parents are critical, abusive, rejecting, or neglectful, the attachment relationship is ruptured. What does that mean?

n n n Secure attachment is defined as the adolescent’s experience of her/his parents as being: caring, responsive to signals of distress, and willing and able to comfort/protect their adolescent when necessary. Secure attachment during adolescence is important because it is what allows the adolescent to turn to her/his parents when she/he is being teased at school, feels like a failure in school, is terribly upset after the break-up with romantic partner, etc. and receive support, guidance and protection. When the attachment is ruptured (i. e. , insecure attachment), parents are no longer available as a resource to soothe and modulate the pain and loneliness

n Moreover, when adolescents do not turn to their parents in times of needs, it can impair the development of important social/cognitive/emotional skills that are important for functioning in general and interpersonal relationships in particular (emotion regulation, perspective taking, problem solving) – skills which buffer against negative mood, hopelessness, depression and suicide.

n n In contrast, when adolescents do turn to their parents to talk about a problem, such discussions provide a context for adolescents to learn and practicing: articulating their feelings, differentiating between emotions, identifying underlying needs/wishes, reflecting on the situation, gaining perspective, and problem solving. Optimally, the parent serves as a partner and guide in this process (they signal that all feelings and thoughts are legitimate [i. e. , psychological autonomy]; ask Socratic open ended questions; resonate and empathize).

In this context, each crises is a learning opportunity for the adolescent – an opportunity to talk, explore, feel, figure things out and develop adaptive responses. n Indeed, much research has found that attachment quality (perceived care and protection) in adolescence is correlated with depression and suicidality. n

n Finally, the attachment relationship is important because parents are there much of the time. They see their child when s/he comes home from school, get’s off the phone with their boyfriend or girlfriend, at meal times and before they go to sleep. When there is contact and disclosure, the parents can be the first to know when the adolescent’s affective state is changing, when they are in trouble, etc.

Attachment in Adolescence n For all of the reasons above, attending to and shaping parent-adolescent interactions and improving the adolescentparent attachment relationship is the primary focus of ABFT.

Reasons for ruptures n In order to work on improving attachment, it helps to have a map of some of events/processes that have impaired or ruptured the adolescent-parent attachment relationship.

n n TRAUMATIC EVENTS: psychological or physical abuse, sexual trauma, abandonment or neglect, etc. CHRONIC NEGATIVE INTERACTIONAL PROCESSES: high levels of parental psychological or behavioral control, low parental affection (e. g. , neglect), parental criticism, parental neglect and conflict.

Interactional patterns preventing the rupture n n Avoiding engaging their adolescent in conversation about what is bothering them, perhaps because they feel guilty, incompetent, overwhelmed, pained. Criticize their child for not “trying harder” and solving their problems themselves. Personalize their child’s distress and become defensive. In short, disappear, lecture, minimize, criticize and blame.

Theory of Change

n n The essential change mechanism is through creating corrective attachment and corrective emotional experiences. 1) Parent (with our preparation and help) adopts an interested, empathic, regulated, nondefensive posture regarding the adolescent’s experiences of what has ruptured the attachment relationship.

n 2) Whatever the content (trauma, chronic negative processes, or feeling like the parents’ responses are not helpful), our aim is to create a conversation in which the adolescent experiences, perhaps for the first time, her/his parent as curious, interested and able to hear and contain their experience (anger, disappointment, sadness, fear, etc. ) without reprisal, criticism, defensiveness.

n n 3) Adolescent feels cared for and safe, and therefore opens up even more, describing her/his experience in a more elaborate and differentiated manner. 4) Parent validates adolescent’s experience, acknowledges that they were not aware of their child’s full feelings and/or their part in that process. Sometimes it includes an apology. Usually includes an explicit commitment to being there for their child more.

n n 5) Child feels validated and secure. 6) Parent may add information that adolescent didn’t know previously.

n n n Leads to new representations or internal working models (or at least experience) of their parents. Parents are perceived as safer, more available, and able to understand protect – better attachment figures. Leads to more approach behaviors by adolescents and satisfaction for adolescent – positive relational cycle.

Unique advantages of Conjoint Family Therapy n n Having the parent (actual object) in the room and discussing the emotional injury with that person is particularly emotionally arousing and meaningful. Research on exposure and experiential based therapies (Foa; Greenberg) Seeing the other make an effort, express care, listen and try to act differently increases hope New interactional cycles are shaped and practiced with both sides of the

Expected Adolescent Outcomes Increase capacity to put feelings into words n Increase tolerance and ability to manage high emotional arousal (rather than acting them out) n Increased ability to express explicitly attachment/relational needs (rather than acting them out) n Enhance capacity for insight, perspective taking (mentalization) and problem solving. n

The ABFT Model

We stand on the shoulders of giants n Structural family therapy Salvador Minuchin n Multidimensional FT Howard Liddle n Emotionally focused therapy Leslie Greenberg and Susan Johnson n Contextual family therapy Boszormenyi-Nagy Ivan n Attachment theory John Bowlby

What is ABFT? n Series of 5 in-session tasks that prepare for and facilitate corrective attachment experiences.

Five Treatment Tasks n Relational Reframe n Alliance with the Adolescent n Alliance with the Parent n Reattachment n Promoting Task Competency Task

ABFT Treatment manual Not a set of rules but a set of principles n Goal Driven n n Flexible in how one reaches the goal Intentionality, intentionality n Not a curriculum but a road map n

Task #1: Relational Reframe n Bond: Building Alliance with family as whole A. Initial focus on strengths, support systems and resources. B. Discussion of depression-suicidal ideation. What are the adolescent’s and parents’ constructions regarding what is the causing the distress. n Sometimes it is family factors (father doesn’t call) n Sometimes it involves things going on outside the family (he gets teased mercilessly at school).

Relational Reframe Next, we implement the essential intervention of this task: C. The Relational Reframe. n Involves changing the focus of the treatment from “what is causing the depression” to “why don’t you go to your mother when you feel so bad about yourself that you want to die? ” n Problem/Solution n “Why don’t you go to your mother when you feel so bad that you want to cut your wrist? ”

Relational Reframe n n Typical questions/interventions that we use to reframe the focus of therapy in relational terms include: “Do you go to your parents to tell them when you feel so bad” “Why not? ” “Mom, do you have any ideas why she doesn’t come to you? ” Sometimes parents have some theories that are usually accurate, sometimes not at all (open door policy”

Relational Reframe – motivation and sign-on n n n “Do you wish it was different? ” “Mom, do you wish she would come to you? ” Don’t get too into the details – not the time to solve the problem. Want to amplify the loss, sadness and motivation. Get the sign-on: “This is exactly what I want to focus on in this treatment – what makes it hard for her to come to you” We can help this be easier. Establish relationship building as the goal

Task #2: Alliance Building with the Adolescent Alone

Three Phases of Adolescent Alone Session 1. Bond Identify Strengths n Engage adolescent in order to increase comfort, reduce tension, suspicion n Establish self as an ally - validate adolescent’s complaints and particularly attachment needs. n “This therapy is not about telling you what to do - I am interested in helping you to be heard” n 2. Individual goals – Go back and identify the problems that concern and are important to the adolescent. “I wish kids would stop teasing me” “I wish my dad would stop putting me down”

Three Phases of Adolescent Alone Session 3. Relational goal (relational reframe) “Why don’t you go to your parents when you feeling so bad, when you are trying to figure this out? ” n YES: What happened? (Lecturing, criticism, minimizing) n NO: Why not? How do you think they’d respond? n If I could get them to listen, would you be willing to tell them so that you could work them through or get support? Get sign-on to trying.

Working with Resistance n n If the adolescent is concerned about burdening their parent: n Why don’t you deserve to have these things addressed? n These things are killing you, they are driving you to self-destruction, you deserve to be heard. n What you are doing is causing your parents more pain. Your parent will grieve for the rest of his/her life if you take yours. n We will support your parents If the adolescent is concerned his/her parent won’t listen: n You’ve never tried it with me. I can make it different. I can make her listen. I will protect you.

Preparation for the reattachment session n Once the adolescent agrees, he/she must be prepared: n n n Therapist helps adolescent prepare what they want to say. Therapist helps the adolescent explore their potential emotional reaction. Help the adolescent process their old behaviors/potential emotional reaction to help them evaluate their behaviors (i. e. , were they effective? Is it a good strategy) in order to gain insight. Discussion about effective ways to communicate in session. Discussion of feared reactions. Problem solving and preparing for patients ineffective

Setting expectations n n Not easy. Parents may not preform perfectly, this is not what they are used to. Patience and forgiveness – successive approximation.

Task #3: Alliance Building with the Parent

Three phases of parent session 1. Bonding • Systematic exploration of strengths and resources • Current Stressors (divorce, drug abuse, money) • Transitional statements – “How do you think this affected your daughter and your relationship with her? ” • Intergenerational Exploration – parents’ own experiences of attachment in their own childhood. • Do you think your daughter feels like she can come to you for help? Would you like to be there for your daughter in a way that your mom was/ was not there for you? 2. Goals • Parental commitment to be there for their adolescent in a different way 3. Task • Preparation for reattachment conversation • Teaching parents Emotion Coaching

Task 4: Reattachment

Reattachment Task n Essentially and in-session enactment. n Task: facilitate productive discussion about core attachment ruptures – not all content is equal n Process: adolescent uses new affect regulation and interpersonal problem solving skills; parents use more emotional coaching. Affect is important – guide family members to access primary, vulnerable emotions (fear, longing, desire to feel loved) n

Reattachment Task n Not teaching, not problem solving n The conversation is between the family members. Therapists are as minimally involved as possible. n If therapist must help facilitate the conversation, gets in and gets out. n But you are sculpting the conversation: the content, the affect and the process

General Structure of the Session Adolescent begins to disclose core content n Anger may be appropriate, but also try to elicit softer, more vulnerable emotions n Parent posture is one of curiosity, validation, questions. n When the time is right, the parents may describe their experience, not as defensiveness or criticism, but in an effort to offer the adolescent new perspective on parents. n

n n Sometimes parents offer an apology and the adolescent offers forgiveness. But it can not be forced. It must remain authentic Therapist helps adolescent see his or her parents as people; non idealized, but as vulnerable as them. Don’t try to wrap it all up nice at the end. Only movies end that way. If there is some resolution, explore what they want from each other going forward.

Task #5: Competency Promoting

Promoting Competency n Re-engage adolescents in social world/activities Identify appropriate challenges and goals n Parent’s are now viewed as a secure base and should be used to support the adolescent in building competency and set reasonable expectations n

ABFT for Depression and Suicide ABFT has shown to be efficacious or effective with depressed and suicidal adolescents in 5 clinical studies. n Larger portion of our research populations have a history of trauma: physical, emotional and sexual abuse. n

Open trial (1995) First clinical trial n Conducted at the Philadelphia Child Guidance Clinic – outpatient center n Showed marked and significant decreases in both depression and suicidal ideation in 15 adolescents. n

Randomized Clinical Trial (1996 -1997) NIMH R 34 treatment development grant n 32 patients, ABFT or wait list control n Significant reductions in percentage of participants diagnosed with diagnosis, level of depressive symptoms, suicidal ideation, and anxiety. Increase in family attachment. n (Diamond, G. S. et al, Journal of the American Academy of Child and Adolescent Psychiatry, 2002). n

Randomized Clinical Trial (2004 -2007) n CDC funded n 66 adolescents randomized to ABFT or Enhanced Usual Care (EUC) 70% female, 80% African American 50% had previous attempts, 30% MDD, 80% Anxiety 50% reported a history of sexual abuse n n (Diamond, G. S. , Journal of the American Academy of Child and Adolescent Psychiatry, 2010).

Suicide Ideation (SIQ)

BDI Response, 50% Reduction from Baseline

Suicide and Sexual Abuse History n Adolescents with a history of sexual abuse are more likely to have: suicide ideation, suicide attempts, and multiple attempts. n Depressed adolescents with a history of sexual abuse did not respond well to Depression focused CBT or CBT plus medication (TADS, TORDIA, etc)

Suicide Ideation – Sex Abuse

Depression – Sex Abuse

ABFT for GLBT Adolescents n n Open trial, 10 GLB adolescents with severe suicidal ideation Phase I – manual development n n more time with parents heighten parents' awareness of micro aggressions help families reduce or resolve parental nonacceptance. Phase II – treatment n n n Average of 12 sessions completed Significant decrease in depressive symptoms and suicidal ideation from baseline to week 6 Decrease in attachment related anxiety from week 6 to end of treatment

Today NIMH - 5 year study n ABFT vs. Family Enhanced Individual Therapy in community mental health clinics n 130 patients randomized n

Israel n ABFT for young adults with unresolved anger toward parents ABFT and EFT reduced psychological symptoms and attachment anxiety and increased forgiveness. n Only ABFT reduced attachment avoidance (i. e. , increase in clients going to parent for support). n

Israel n Current study using ABFT to help mend relationships among LGB young adults and their non-accepting parents

Trainings n Trainings in Belgium, Sweden, Norway, Denmark, Italy, Spain, Poland, Australia, US and Israel בית הספר החדש לפסיכותרפיה http: //thenewschool. co. il/ gdiamond@bgu. ac. il