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2/19/2020
©ABFT Training. Please do not reproduce without permission. 1
Building Resiliency: The Role Attachment‐Based Family Therapy Can Play in Treating Youth
Suicide and Depression
Conflicts of Interest Disclosure
Dr. Suzanne Levy has received salary support via grants from the National Institute of Mental Health, American Foundation for Suicide Prevention, royalties from Attachment‐Based Family Therapy (ABFT; 2014) book sales and honoraria and salary support for ABFT trainings and supervision.
Center for Family Intervention ScienceABFT Training Program
Guy Diamond, Ph.D., Director‐ Center for Family Intervention Science, Associate Professor, College
of Nursing and Health Professionals, Drexel University
Gary Diamond Ph.D., ‐ Professor and Chair of the Department of Psychology, Ben Gurion University, Israel; http://www.bgupsychotherapyresearch.org/
Suzanne Levy, Ph.D., Training Director‐ ABFT Training Program, Drexel University, College of Nursing and Health Professions ([email protected])
Websites
www.ABFTtraining.com/www.Drexel.edu/abft
www.facebook.com/Attachment.Based.Family.Therapy
Follow us on Twitter and Instragram (@ABFTtraining) and Youtube
ABFT Belgium Training Center: https://ppw.kuleuven.be/ogop/abft
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Adolescent Suicide Statistics
• Endorse feeling sad or depressed most days in the past year38%
•Seriously considered attempting suicide16%
•Reported making a suicide attempt10%
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Among middle and high school students (Pennsylvania’s Office of the Governor, 2018 ):
Overview of ABFT
Brief Treatment
Developed for: Depressed and Suicidal youth
5 distinct, yet interrelated tasks
Manual, focused but flexible
Aims to build family as a resource for the suicidal teen
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Theory of Healthy Functioning
Secure Attachment (Bowlby, 1969)
Child has an emotional need
Caregivers are available,
responsive and attuned
Child feels loved and protected by
parents
Child believes they are worthy of
love and protection
Child more likely to seek support and feel safe to explore the world
Working model/Schema
Development of Emotion Regulation (Eisenberg et al., 2010)
Attachment Need Activated
Turn to parent for protection
Child’s fears are calmed
Self‐soothinginternalized
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Parenting Skills that Promote Attachment and Affect Regulation (Ginott, 2009; Gottman et al., 1997; 2011)
Acceptance of negative emotion
Validation of emotional experience
Help adolescent develop an emotional vocabulary
Parental expression of emotion
Conflicts resolved through negotiation and compromise
Authoritative Parenting(Baumrind, 1989)
Warmth Structure
Cross cultural support: contextual modifications (e.g., urban, low SES)
vs
Warmth
Structure
Warmth
Structure
Attachment in Adolescence
(Allen & Land, 1999, Steinberg, 1990)
Context: Supportive and respectful adolescent‐parent relations
Central task: Develop autonomy and maintain attachment
Moderate conflict: Facilitates identity development
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Family as protective factor(Kaslow, et al., 1994; Restifo & Bogels, 2009)
Parental Warmth
Parental Sensitivity
Better adolescent functioning and lower depression
Theory of Pathology
Insecure Attachment (Bowlby, 1969)
Child has an attachment need
Caregiver fails to be available, responsive and/or attuned
Child feels unprotected and unloved
Child develops low expectation of caregiver’s availability for support and
protection
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Attachment Style and Parenting (Jones, Cassidy, & Shaver, 2015)
Risk Factors for Insecure Attachment
Life Events/Trauma
Caregiver Stress
Family Interaction Patterns
Child Factors
Attachment‐Based Theory:Adolescent Depression and/or Suicide
Insensitive Caregiving
Attachment Ruptures
Depression and/or Suicide
ADOLESCENT PARENT
Insecure Attachment Style
Emotional Dysregulation Psychopathology
Intergenerational Attachment Patterns:
Conflict over Attachment and
AutonomyCurrent Stressors
Other contributing
factors
Feeling unworthy of love and protection
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Family as Safety Net
Strengthening families
Empirical Support
ABFT has shown to be effective with depressed and/or suicidal adolescents in 6 studies (Diamond et al., 2016)
Promising Practices Network: Proven practice
NREPP: Effective for depression and suicidal ideation
California Evidenced-Based Clearinghouse for Child Welfare (CEBC): “Promising Research Evidence” for adolescent depression
Swedish Guidelines for treatment of Depression
CYP IAPT recommended treatment in England
Dissemination EffortsInternationally in: Nationally in:
• Australia• Belgium • Canada• Croatia• England• Germany• Iceland• India• Ireland• Israel• Italy• Netherlands• Norway• Sweden• Turkey
• Arkansas• California• Colorado• Connecticut• Delaware• Georgia• Illinois• Indiana• Kansas• Maine• Maryland• Massachusetts
• Minnesota • Missouri• Nebraska• New Jersey• New York• North Carolina• Oregon• Pennsylvania• Texas• Utah• Virginia• Washington D.C
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Clinical Model
Five Treatment Tasks
Relational Reframe
Adolescent Alliance
Parent Alliance
Attachment
Promoting Autonomy
Task 1: Relational Reframe
Goal
Shift from patient as the problem to family relationships as the solution
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Task 1: Relational Reframe
Highlight: ruptures and consequences• “When you are feeling so sad or afraid, why don’t
you go to your mom or dad for support?”
• “What’s the impact of dealing with issues all alone?”
Responsibility of change on all family members
Task 1: Relational Reframe
Establish a treatment contract: Relationship repair
Task
Task 1 Video
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Task 2: Alliance with Adolescent
Bond
Meet alone with the adolescent
Alliance with adolescent
Task 2: Alliance with Adolescent
Coherent
Attachment
Narrative
Breaches of Parental Trust
Related Primary emotions
Impact of Ruptures
Attachment
Themes
Mental Health
Problem Narrative
Amplify Entitlement
Goal
Examples of RupturesTraumatic Events • “My mom didn’t protect me when dad was
abusing us. How can I trust her now?”
Negative family interactions• “My dad does not accept me.”• “My mom is critical and controlling.”• “My parents don’t understand me and try to
solve my problems.”
Parental psychopathology• “My mom freaks out (anxious) when I tell her my
problems.” • “I don’t want to burden my mom, she has
enough on her plate.”30
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Task 2: Alliance with Adolescent
Prepare adolescent for attachment task
Task 3: Alliance with Caregiver/Parent
Bond
Meet alone with the caregiver(s)
Determine who comes to the session.
Task 3: Alliance with Caregiver/Parent
Activate caregiver’s caregiving instinct.
Goal
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Task 3: Alliance with Caregiver/Parent
“It must be hard raisingan adolescent, let alone a depressed one when you are juggling so much. How has that impacted you?”
“Nobody was there for you when you were growing up, and now you don’t know how to be there for your son”
Task 3: Alliance with Caregiver/Parent
Prepare adolescent for attachment task
Emotion Coaching: The Five Steps
Be aware of a child’s emotions
Recognize emotion as a chance to get closer
Help child label emotions
Listen empathetically and validate child’s feelings
Begin problem‐solving only after child feels understood
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Guidelines for Dealing with Suicidal Adolescents (adapted from Brown et al.,2001)
Be very attentive, not detached
Remain calm and non‐threatened
Give the adolescent space and time to express themselves
Be willing to say the word “suicide” without flinching
At all costs, do not express anger, exasperation, or passive hostility
Do not immediately suggest hospitalization
Task 4: Attachment Task
Goal
Conversations about core attachment
ruptures
Resolves Conflicts
Begins to change relational expectations
Adolescent practices conflict resolution and emotion
regulation skills
Caregivers practice emotionfocused caregiving skills
Task 4: Attachment Task
Process
Adolescent discloses and
discusses ruptures
Caregiver(s) offer empathy and
acknowledgment
Therapist redirects as needed
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Task 4 Video
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Task 5: Autonomy Promoting Task
Goal
Revitalize a goal corrected partnership
Cooperation from desire
for connection
Caregivers viewed as
secure base
Task 5: Autonomy Promoting Task
Content of
Sessions
Factors contributing to depression and suicide
Emerging Maturity in
home
Build Competency
Identity Development
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Closing Statements
ABFT is all about relationship building!
Focusing conversations on the relationship is more engaging for the family
Caregivers play an essential role in helping their teens cope with depression and suicidal thoughts.
• Your adolescents need you, even if they do not show it
• Sometimes kids just need to be heard and not helped
• Find the right balance of warmth and structure
For more information:
Please contact: Suzanne Levy at [email protected]/abft
References • Allen, J. P., & Land, D. (1999). Attachment in adolescence. In Cassidy, Jude (Ed);
Shaver, Phillip R. (Ed). (1999). Handbook of attachment: Theory, research, and clinical applications (pp. 319‐335). New York: Guilford Press
• Baumrind, D. (1989). Rearing competent children. In W. Damon (Ed.), The Jossey‐Bass social and behavioral science series. Child development today and tomorrow (p. 349–378). Jossey‐Bass.
• Brown, G. K., Bruce, M. L., & Pearson, J. L. (2001). High‐risk management guidelines for elderly suicidal patients in primary care settings. International Journal of Geriatric Psychiatry, 16, 593‐601.
• Bowlby, J. (1969). Attachment and Loss. New York: Basic Books
• Diamond, G.S.; Diamond, G.M.; & Levy, S.A. (2014). Attachment‐Based Family Therapy for Depressed Adolescents. American Psychological Association
• Diamond, G., Russon, J. & Levy, S. (2016), Attachment‐Based Family Therapy: A Review of the Empirical Support. Family Process, 55(3), 595‐610. doi:10.1111/famp.12241
• Eisenberg, N., Spinrad, T. L., Eggum, N. D., Silva, K. M., & Reiser, M. (2010). Relations among maternal socialization, effortful control, and maladjustment in early childhood. Development and Psychopathology, 22(3), 507‐525. doi: 2110/10.1017/S0954579410000246.
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References Cont’d• Ginott, H. G. (2009). Between parent and child: The bestselling classic that
revolutionized parent‐child communication. Crown Archetype.
• Gottman, J (2011). Raising an emotionally intelligent child. Simon & Schuster. NY: NY
• Gottman, J.M., Katz, L.F., & Hooven, C. (1996). Parental meta‐emotion philosophy and the emotional life of families: Theoretical models and preliminary data. Journal of Family Psychology, 10(3), 243‐268
• Jones, J. D., Cassidy, J., & Shaver, P. R. (2015). Parents' self‐reported attachment styles: a review of links with parenting behaviors, emotions, and cognitions. Personality and social psychology review : an official journal of the Society for Personality and Social Psychology, Inc, 19(1), 44–76. https://doi.org/10.1177/1088868314541858
• Kaslow, N. J., Deering, C. G., & Racusin, G. R. (1994). Depressed children and their families. Clinical Psychology Review, 14, 39‐59.
• Pennsylvania Office for the Governor (2018). School Safety Task Force Report [PDF file]. Retrieved from https://www.governor.pa.gov/wp‐content/uploads/2018/08/20180827‐Gov‐Office‐School‐Safety‐Report‐2018.pdf
• Restifo, K., & Bogels, S. (2009). Family processes in the development of youth depression: translating the evidence to treatment. Clinical Psychology Review, 29(4), 294‐316.
• Steinberg, L (1990). Autonomy, conflict and harmony in the family relationships. In S.S. Feldman and G.R. Elliot (Eds.). At the threshold: the developing adolescent, (pp. 255‐276). Cambridge Mass; Harvard University Press.
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