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Attachment-Based Family Therapy (ABFT)

Topic Areas
Scientific Rating
Child Welfare Relevance
Depression Treatment (Child & Adolescent)
3  — Promising Research Evidence
Medium

About This Program

Target Population: Adolescents and young adults (12-26) with elevated depression symptoms, clinically diagnosed major depressive disorder, suicidal ideation and behaviors, dispositional anxiety, and family conflict; and their families

For children/adolescents ages: 12 – 25

For parents/caregivers of children ages: 12 – 25

Program Overview

ABFT is an attachment-based, trauma-informed, emotion-focused intervention for youth with suicide, depression anxiety, and/or trauma. Treatment strengthens secure parent-child relationships which can reduce family conflict and buffer against stress. The model is structured yet flexible, requiring therapists to be focused as well as emotionally attuned. Treatment is constructed around five tasks:

  • The Relational Reframe task helps families focus on relationship repair as the initial goal of therapy.
  • The Adolescent Alliance task helps link current distress to attachment ruptures and prepares the adolescent to talk about this with caregivers.
  • The Parent Alliance task focuses on reducing caregiver distress, increasing empathy, and improving parenting skills.
  • The Attachment Task brings the family members back together to discuss these attachment ruptures. This helps families resolve problems and practice new interpersonal and affect regulation skills.
  • As trust reemerges, therapy focuses on Promoting Autonomy task, wherein caregivers help promote adolescent autonomy and competency outside the home.

ABFT is generally delivered in weekly sessions for 12-16 weeks.

Program Goals

The overall goals of Attachment-Based Family Therapy (ABFT) are:

  • Decrease depression
  • Decrease suicidal ideation and behavior
  • Decrease adolescent's negative self-concept
  • Improve family functioning
  • Decrease family conflict
  • Improve affect regulation of the family
  • Decrease parent criticism/hostility
  • Increase adolescent secure attachment to caregivers
  • Increase attachment promoting parenting skills

Logic Model

The program representative did not provide information about a Logic Model for Attachment-Based Family Therapy (ABFT).

Essential Components

The essential components of Attachment-Based Family Therapy (ABFT) include:

  • Family therapy with one adolescent/young adult and at least one caregiver (may include multiple caregivers)
  • Used in outpatient settings, home-based services, inpatient hospital settings, residential treatments, day treatments, and partial treatment programs
  • Typically weekly therapy sessions (60-90 minutes long), but can be adapted to fit context
  • Therapist meets with adolescent/young adult and caregiver together and alone
  • The therapy is divided into 5 distinct, yet interrelated tasks that build on one another.
    • Task 1: Relational Reframe Task (1 joint session)
      • Problem state targeted: Lack of trust, caregiver criticism and/or hostility, and honest communication
      • After establishing rapport and the presenting problem, the therapist shifts the focus of the conversation from the adolescent/young adult as the problem, to a focus on the caregiver(s)–adolescent relationship as the solution.
      • The therapist helps family members identify what gets in the way of the adolescent/young adult using their caregiver(s) for emotional support (i.e., ruptures) and the consequences of the ruptures. They also help amplify the adolescent's/young adult's and caregiver(s)' longing to be (re)connected.
      • Goal: Reduce the adolescent's/young adult's feelings of being the problem and that they are the ones who need to change and increase mutual responsibility (adolescent/young adult and caregiver(s)) for improving youth functioning
      • Task: Establish agreement to work on improving the caregiver(s)-youth relationship as the first goal of treatment
    • Task 2: Adolescent Alliance Task (2 to 4 individual sessions with adolescent/young adult)
      • Problem state targeted: Adolescent/young adult motivation to have an improved relationship with caregiver(s)
      • Therapist assists adolescent/young adult in constructing a more coherent mental health problem narrative.
      • Therapist assists adolescent/young adult in constructing a more coherent attachment narrative.
      • Goal: Link mental health and attachment narratives to motivate and get commitment from adolescents/young adults to address these issues with their caregiver(s)
      • Task: Prepare adolescent/young adult to talk with caregiver(s)
    • Task 3: Parent Alliance Task (2 to 4 individual sessions with caregiver(s))
      • Problem state targeted: Insensitive caregiving practices
      • Therapist explores caregiver(s)' current stressors and its impact on caregiving.
      • Therapist and caregiver(s) explore how couple's conflict may impact caregiving (if applicable).
      • Therapist and caregiver(s) explore caregiver(s)' intergenerational history and its impact on caregiving.
      • Therapist teaches caregiver(s) emotion coaching parenting skills.
      • Goal: Caregiver(s) are motivated to listen to adolescent/young adult grievances and support their youth in a new, more attachment promoting manner.
      • Task: Prepare caregiver(s) to talk with their adolescent/young adult in joint sessions about relational ruptures.
    • Task 4: Attachment Task (1 to 4 joint sessions)
      • Problem state targeted: Insecure attachment, family disengagement and/or conflict.
      • Therapist coaches adolescent/young adults to share honest and vulnerable thoughts, memories, and feelings directly with caregiver(s).
      • Therapist coaches caregiver(s) to be emotionally responsive and attuned rather than becoming defensive and trying to offer solutions to problems.
      • Goal: Engineer a corrective attachment experience that helps begin to rebuild trust and respect among adolescent/young adults and their caregiver(s).
      • Task: Coach caregiver(s) and adolescent/young adults to discuss with one another, all relational ruptures that have inhibited trust in the parent-child relationship
    • Task 5: Autonomy Promoting Task (4 to 20 majority joint sessions)
      • Problem state targeted: Repair adolescent/young adult negative self-concept and mental health distress and impairment by increasing adolescent autonomy and competency. Continue to rebuild trust in the caregiver(s)-youth relationship.
      • Therapist coaches caregiver(s) and adolescent/youth to discuss issues that help promote age appropriate adolescent development, autonomy, competency and reduce mental health distress. Topics include things such as factors that contribute to the mental health issues, building competency outside of the home, emerging maturity in the home and identity development.
      • Therapist supports caregiver(s) in serving as a secure base for their adolescent/young adult.
      • Therapist supports adolescent/youth in taking responsibility for their behavior/actions.
      • Therapist coaches caregiver(s) and adolescent/youth to build more competent communication skills.
      • Goal: Re-vitalize a goal corrected partnership wherein caregivers are viewed as the adolescent/youth's secure base and all parties cooperate in order to maintain connection to one another.
      • Task: Help caregiver(s) and adolescent/young adults identify and discuss important topics wherein both are using more attachment promoting communication skills and caregiver(s) serve as the secure base.
  • Therapists use emotional deepening techniques throughout the therapy to elicit primary emotions and sustain emotional moments.
  • Therapists take a directive and supportive stance, modeling an authoritative caregiver throughout therapy. To clarify, authoritative caregivers retain authority and control, but are warm, supportive, and communicative versus authoritarian parents who are very strict and controlling with little warmth.
  • Therapist or case coordinators (when available) provide resource coordination as needed.

Program Delivery

Child/Adolescent Services

Attachment-Based Family Therapy (ABFT) directly provides services to children/adolescents and addresses the following:

  • Depression, depressive symptoms, suicidal ideation and behaviors, poor family communication, family conflict, parental criticism/hostility, insensitive parents, family disengagement, negative self-concept

Parent/Caregiver Services

Attachment-Based Family Therapy (ABFT) directly provides services to parents/caregivers and addresses the following:

  • Parental criticism/hostility, parental depression, parent-child conflict, insensitive parenting, family disengagement; parent of a child with depression, suicidal ideation, and/or suicidal behavior
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Siblings and other supportive adults are typically involved in Task 5 of the treatment, however they may be brought in earlier in treatment if deemed clinically appropriate and beneficial by the therapist. Therapists provide family resource coordination when needed. Therapists often are in contact with schools and other clinicians involved with the family (e.g., individual therapists, couple's therapist, psychiatrist, influential religious leaders, etc.) when appropriate.

Recommended Intensity:

Weekly for 60-90 minutes. When in Tasks 2 (alone with the adolescent) and 3 (alone with the parent), two sessions a week may be needed. This could be on different days or consecutive sessions.

Recommended Duration:

Typically 12-16 weeks, but can also be utilized for longer periods of time (e.g., 6 months, 1 year) with a family

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

This program does not include a homework component.

Languages

Attachment-Based Family Therapy (ABFT) has materials available in languages other than English:

Dutch, Hebrew, Norwegian, Swedish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Therapists only need a space to deliver the therapy.

A web-based outcomes-monitoring tool (The Behavioral Health Screen) that requires a computer tablet and internet connection is offered as well (optional resource).

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Therapists in the U.S. need to have at least a Master's degree in the mental health field such as social work, mental health counseling, clinical or counseling psychology, psychiatry or couple's and family therapy. If therapists are not licensed, they need to be employed somewhere where they are receiving supervision. Internationally, therapists need to have local certification or licensure allowing them to practice therapy.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-Based Family Therapy for Depressed Adolescents. American Psychological Association

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Introductory and Advanced workshops are offered yearly (2x/year for Introductory trainings) online. Onsite training at trainee's organizations worldwide is also available. Additionally, ABFT Training is offered at KU Leuven University in Leuven, Belgium, yearly.

Number of days/hours:

To do ABFT with clients, a therapist should, at a minimum, read the ABFT manual, Attachment-Based Family Therapy for Depressed Adolescents, and/or complete Level 1 training with 24 hours of training during a 3-day Introductory Workshop. Therapists may also participate in Level 2 which consists of 24 hours of additional training during a 3-day Advanced workshop and/or 22 web-based group consultation sessions (60 or 90 minutes).

To become certified in ABFT, therapists must complete Level 1, Level 2, and Level 3 which consists of therapy tape review of 10 one-hour client sessions. To become a certified ABFT Supervisor, one must first become a certified ABFT Therapist. Then it takes approximately 19 hours of training to become a certified ABFT Supervisor.

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Attachment-Based Family Therapy (ABFT) as listed below:

When agencies are incorporating ABFT into their program, several initial phone and or face-to-face planning meetings are recommended between the ABFT training staff and the agency. Before the initial meeting, agencies will be asked to provide a description of the following (Agency Description – ABFT Implementation form):

  • Current programs, including types of clients seen
  • Referral process and sources
  • Family involvement (e.g., is family involved in treatment or just intake)
  • Staff profiles (e.g., degrees and training of staff)
  • Staff turnover rates
  • Funding sources and patient mix for current programs (e.g., private insurance, Medicaid, etc.)
  • Projected funding sources to fund ABFT training
  • Possible stakeholders
  • Previous experience with manualized treatment protocols.

Therapists are asked to complete some questionnaires; the ABFT Empirically Based Treatment Questionnaire, as well as the Theoretical Orientation Self-Test.

Formal Support for Implementation

There is formal support available for implementation of Attachment-Based Family Therapy (ABFT) as listed below:

Case Consultation:
The ABFT Training Program provides formal support to programs wanting to be trained further in ABFT. This includes case consultation, fidelity monitoring, and program effectiveness evaluation. After completing Level 1, training therapists may participate in bimonthly, 60- or 90-minute group case consultation video web-conferencing calls with an ABFT certified consultant. Therapists are asked to commit to at least 11 sessions at a time (no upper limit). If a therapist wants to become certified, they must participate in a minimum of 22 sessions. Supervision is provided via a HIPPA-secure web-conferencing platform (Zoom). In order to participate in supervision, therapists must have access to a computer with a web camera. To become certified, therapists must bring video recordings of their therapy sessions to supervision.

Case Consultation & Fidelity Ratings:
The ABFT Training Program also offers videotape review for therapists. After attending the advanced workshop, trainees can begin submitting their 10 (minimum) videotaped complete ABFT sessions for review by certified supervisors. The ABFT supervisor informs the therapist of which tasks or portions of a task to submit. When submitting tapes, therapists must provide a case write-up (template provided) and self-feedback on their tapes with suggestions for how to improve portions of their sessions that are not consistent with ABFT or could be improved in general. Therapists also rate their own tapes with the ABFT treatment fidelity measure. ABFT certified supervisors review the tapes and provide in-depth written feedback, ABFT treatment fidelity ratings, as well as 20 minutes of phone consultation regarding the tape. Tapes are submitted to the ABFT Training Program via a secure FTP program (LiquidFiles). If therapists desire supervision beyond the certification process, they may pay for ongoing supervision and/or tape review. Email and phone consultation outside of bimonthly group supervision sessions or video review are provided on a limited basis. Therapists must participate in group supervision and/or video review for email and phone consultation service beyond one time.

Program Effectiveness:
It is recommended that agencies gather baseline, weekly, and posttreatment outcome data from families participating in ABFT. Doing so is designed to improve clinical monitoring, help focus the therapist on clinical outcomes, and ideally provide ongoing demonstration of the program's clinical effectiveness to the community and payers. It is recommended to do a brief assessment of depression and suicidal ideation before every session. If that is not feasible, then it is recommended to do this assessment at intake, 4, 8, 12, and 16 weeks.

Agencies have many options for how to collect data and analyze it once it is collected. These options can be discussed with the ABFT staff before program implementation. It is strongly recommended to use the web-based, Behavioral Health Screen (BHS; additional cost).

Behavioral Health Screen:
The BHS is a 100% web-based, self-report, comprehensive solution for assessment of the 13 major domains in behavioral and mental health issues recommended or required by the American Academy of Pediatrics, American Psychiatric Association, and The Joint Commission. The BHS has strong psychometric support and has been validated for youth through young adults, 12 to 24 years old. The BHS takes up to 10 minutes to complete. The flexible web tool and platform allows for site-specific additional assessment items. More information can be found on the ABFT website.

Alternative Recommended Battery:
For those agencies who do not wish to use the BHS, there is a battery of recommended measures including measures on depressive symptoms, suicidal ideation, trauma, relationship closeness, client satisfaction, and therapeutic alliance. ABFT is willing to work with agencies who have their own battery of assessment tools as well.

Fidelity Measures

There are fidelity measures for Attachment-Based Family Therapy (ABFT) as listed below:

Therapist Behavior Rating Scale-3 (TBRS-3):
The Therapist Behavior Rating Scale-3 (TBRS-3) is a 29-item measure designed to capture prescribed and emphasized ABFT therapist behaviors, including 5 essential ABFT interventions (e.g., relational reframes, focus on vulnerable emotions, planning reattachment episodes, conducting reattachment episodes, focus on core relational themes), 5 more general family therapy skills (e.g., enactment, discussing parental monitoring), and 4 alliance building skills (e.g., expressing empathy). For differentiation purposes, 4 CBT interventions (e.g., homework, challenging distorted cognitions) are included. The scale has two categories, Behavior Rating Scale (20 items) and Global Ratings of Therapy Sessions (9 items).

Therapists and supervisors are trained on this measure using the TBRS-3 Manual. Supervisors are trained to have their ratings reliable amongst one another.

2nd Generation ABFT Adherence Measures:
There are 5 adherence checklist measures, one for each task. Therapist certification depends on the ability of a therapist to deliver specific elements of the task in a competent and sensitive manner. The measures are not meant to be restrictive, but to provide some foundation upon which to judge how well a given task is going and to keep the therapist focused even with the full range of idiosyncratic material presented by each family.

These checklists include the ideal phases within and essential elements of each task. Therapists are rated on how thoroughly they complete each phase listed. Therapists get a higher rating as they include more of those elements (cumulative judgment). The highest scores contain elements of competency, rating the therapist's ability to administer the model responsively and respectfully or with more emotional focus. The ratings scales are very detailed and specific.

Therapists attending days 2 and 3 of the introductory workshop are provided with the adherence measures, oriented to how to use them, and they are used during the workshop (when watching videos of sessions or live sessions). The adherence measures are also used in the Advanced Workshop. Therapists who participate in the certification process are given ongoing guidance on how to use the measures. ABFT supervisors are trained on how to use these measures and regularly meet to assure interrater reliability.

For a copy of all measures and TBRS-3 Training Manual, contact the Training Contact listed above.

Fidelity Measure Requirements:

Self-report checklists by therapists, ratings by certified ABFT supervisors from video recorded therapy sessions and/or live supervision.

Established Psychometrics:

The Therapist Behavior Rating Scale-3 (TBRS-3) is a validated measure.

Diamond, G. M., Diamond, G. S., & Hogue, A. (2007). Attachment-based family therapy: Adherence and differentiation. Journal of Marital and Family Therapy, 33(2), 177–191. https://doi.org/10.1111/j.1752-0606.2007.00015.x

Implementation Guides or Manuals

There are implementation guides or manuals for Attachment-Based Family Therapy (ABFT) as listed below:

The Dissemination and Implementation Starter Packet describes the materials, resources, and systems that are needed and available to support implementation of ABFT within an agency. It describes the requirements for evaluating agency readiness, expectations of clinic investment, and therapist eligibility. Possible funding sources for sustainability purposes are described. The guide outlines the therapist certification process. There is also a FAQ section.

For a copy of the Dissemination and Implementation Starter Packet, contact the Training Contact listed above.

Implementation Cost

There are no studies of the costs of Attachment-Based Family Therapy (ABFT).

Research on How to Implement the Program

Research has been conducted on how to implement Attachment-Based Family Therapy (ABFT) as listed below:

Devacht, I., Bosmans, G., Dewulf, S., Levy, S., & Diamond, G. S. (2019), Attachment-Based Family Therapy in a psychiatric inpatient unit for young adults. Australian and New Zealand Journal of Family Therapy, 40, 330–343. http://doi.org/10.1002/anzf.1383

Ringborg, M. (2016). Dissemination of Attachment-Based Family Therapy in Sweden. Australian & New Zealand Journal of Family Therapy, 37, 228–239. http://doi.org/10.1002/anzf.1153

Santens, T., Levy, S. A., Diamond, G. S., Braet, C., Vyvey, M., Heylboeck, E., & Bosmans, G. (2017). Exploring acceptability and feasibility of evidence-based practice in child welfare settings: A pilot study with Attachment-Based Family Therapy. Psychologica Belgica, 57(1), 43–58. http://doi.org/10.5334/pb.338

Santens, T., Hannes, K., Levy, S., Diamond, G. & Bosmans, G. (2020). Barriers and facilitators to implementing Attachment-Based Family Therapy into a child welfare setting: A qualitative process evaluation. Family Process, 59(4), 1483–1497. https://doi.org/10.1111/famp.12504

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-Based Family Therapy for depressed adolescents: A treatment development study. Journal of the American Academy of Child & Adolescent Psychiatry, 41(10), 1190–1196. https://doi.org/10.1097/00004583-200210000-00008

Type of Study: Randomized controlled trial
Number of Participants: 32

Population:

  • Age — 13–17 years (Mean=14.9 years)
  • Race/Ethnicity — 69% African American and 31% White
  • Gender — 78% Female
  • Status — Participants were adolescents meeting the DSM-III-R criteria for major depressive disorder (MDD).

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the present study was to design a treatment manual and adherence measure as well as test the efficacy of Attachment-Based Family Therapy (ABFT) for adolescent depression. Participants were randomly assigned to 12 weeks of ABFT or a 6-week, minimal-contact, waitlist control group. Measures utilized include the Child Behavior Checklist (CBCL), the Brief Symptom Inventory (BSI), the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale (HAM-D), the Self-Report of Family Functioning (SRFF), the Inventory of Parent and Peer Attachment, the Beck Hopelessness Scale, the Suicidal Ideation Questionnaire, the Youth Self-Report, the State-Trait Anxiety Inventory for Children: A-Trait (STAIC), and the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode version (KSADS-P). Results indicated that at posttreatment, 81% of the patients treated with ABFT no longer met criteria for major depressive disorder (MDD), in contrast with 47% of patients in the waitlist group. Additionally, compared with the waitlist group, patients treated with ABFT showed a significantly greater reduction in both depressive and anxiety symptoms and family conflict. Of the 15 treated cases assessed at the follow-up, 13 patients continued to not meet criteria for MDD 6 months after treatment ended. Limitations include small sample size, waitlist condition lasted only half as long as the treatment condition, and lack of generalizability due to ethnicity and socioeconomic status.

Length of controlled postintervention follow-up: None.

Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K., & Levy, S. (2010). Attachment-Based Family Therapy for adolescents with suicidal ideation: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 49(2), 122–131. https://doi.org/10.1016/j.jaac.2009.11.002

Type of Study: Randomized controlled trial
Number of Participants: 66

Population:

  • Age — 12–17 years (Mean=15.1 years)
  • Race/Ethnicity — 74% African American
  • Gender — 83% Female
  • Status — Participants were adolescents with severe suicidal ideation and moderate depressive symptoms in primary care and emergency departments.

Location/Institution: Department of Psychiatry at the Children's Hospital of Philadelphia

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate whether Attachment-Based Family Therapy (ABFT) is more effective than enhanced usual care (EUC) for reducing suicidal ideation and depressive symptoms in adolescents. Participants were randomly assigned to ABFT or EUC. Measures utilized include the Suicidal Ideation Questionnaire (SIQJR) and the Beck Depression Inventory (BDI-II). Results indicated that patients in ABFT demonstrated significantly greater rates of change on self-reported suicidal ideation at posttreatment evaluation, and benefits were maintained at follow-up, with a strong overall effect size. Significantly more patients in ABFT met criteria for clinical recovery on suicidal ideation posttreatment than patients in EUC. Benefits were maintained at follow-up. Patterns of depressive symptoms over time were similar, as were results for a subsample of adolescents with diagnosed depression. Retention in ABFT was higher than in EUC. Limitations include small sample size, findings may not generalize to more affluent or culturally heterogeneous samples, and short follow-up limits the understanding of long-term treatment benefits.

Length of controlled postintervention follow-up: 24 weeks.

Diamond, G., 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(4), 595–605. https://doi.org/10.1037/a0028414

Type of Study: Randomized controlled trial
Number of Participants: 66

Population:

  • Age — 12–17 years (Mean=15.1 years)
  • Race/Ethnicity — 74% African American
  • Gender — 83% Female
  • Status — Participants were adolescents with severe suicidal ideation and moderate depressive symptoms in primary care and emergency departments.

Location/Institution: Department of Psychiatry at the Children’s Hospital of Philadelphia

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same sample as Diamond et al. (2010). The purpose of the study was to evaluate if a history of sexual trauma (HSA) moderated treatment outcomes for Attachment-Based Family Therapy (ABFT). Participants were randomly assigned to ABFT or Enhanced Usual Care (EUC). Measures utilized include the Suicide Ideation Questionnaire-JR (SIQ-JR), the Diagnostic Interview Schedule for Children, the Scale for Suicidal Ideation-Past Week (SSI-PW), the Beck Depression Inventory-II (BDI-II) and the Self-Report of Family Functioning (SRFF). Results indicate that HSA did not moderate treatment outcome for ABFT. Adolescents responded better to ABFT than a control condition, regardless of HSA status. At baseline, adolescents with HSA were also more likely to report past suicide attempts than those without HSA. Limitations include small sample size, lack of generalizability due to ethnicity and gender, and length of follow-up.

Length of controlled postintervention follow-up: 24 weeks.

Shpigel, M. S., Diamond, G. M., & Diamond, G. S. (2012). Changes in parenting behaviors, attachment, depressive symptoms, and suicidal ideation in Attachment‐Based Family Therapy for depressive and suicidal adolescents. Journal of Marital and Family Therapy, 38(s1), 271–283. https://doi.org/10.1111/j.1752-0606.2012.00295.x

Type of Study: Randomized controlled trial
Number of Participants: 18

Population:

  • Age — 14–18 years (Mean=16.5 years)
  • Race/Ethnicity — 81% African American, 14% European American, and 5% Latino
  • Gender — 85% Female
  • Status — Participants were adolescents with clinical levels of suicidal Ideation and their parents.

Location/Institution: Philadelphia

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same sample as Diamond et al. (2010). The purpose of the study was to examine whether Attachment-Based Family Therapy (ABFT) was associated with decreases in maternal psychological control and increases in maternal psychological autonomy granting, and whether such changes were associated with changes in adolescents’ attachment schema and psychological symptoms. Participants were randomly assigned to ABFT or to enhanced usual care (EUC). Measures utilized include the Parental Bonding Instrument (PBI), the Relationship Scale Questionnaire (RSQ), the Suicide Ideation Questionnaire-Jr. (SIQ-Jr), and the Beck Depression Inventory-II (BDI-II). Results indicate that from session 1 to session 4, maternal psychological control decreased and maternal psychological autonomy granting increased. Increases in maternal autonomy granting were associated with increases in adolescents’ perceived parental care from pretreatment to midtreatment and decreases in attachment-related anxiety and avoidance from pretreatment to 3 months posttreatment. Finally, decreases in adolescents’ perceived parental control during the treatment were associated with reductions in adolescents’ depressive symptoms from pretreatment to 12 weeks posttreatment. Limitations include small sample size, lack of analysis on the control group, reliance on self-reported measures, only a subsample of the original larger sample was followed, and lack of generalizability due to gender and ethnicity.

Length of controlled postintervention follow-up: None.

Israel, P., & Diamond, G. S. (2013). Feasibility of Attachment Based Family Therapy for depressed clinic-referred Norwegian adolescents. Clinical Child Psychology and Psychiatry, 18(3), 334–350. https://doi.org/10.1177/1359104512455811

Type of Study: Randomized controlled trial
Number of Participants: 20

Population:

  • Age — 13–17 years (Mean=15.6 years)
  • Race/Ethnicity — Not specified
  • Gender — 55% Female
  • Status — Participants were clinic-referred adolescents with major depression.

Location/Institution: Norway

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the feasibility of importing Attachment-Based Family Therapy (ABFT) into a hospital-based outpatient clinic in Norway. Participants were randomly assigned to ABFT or to treatment as usual (TAU). Measures utilized include the Hamilton Depression Rating Scale (HAM-D), the Youth Self Report (YSR), the Beck Depression Inventory-II (BDI-II) and the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS-PL). Results indicate that adolescents in ABFT showed significantly better symptom reduction compared to adolescents in TAU. Limitations include small sample size, reliance on self-reported measures, weak control group of limited or no therapy, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Feder, M. M., & Diamond, G. M. (2016). Parent–therapist alliance and parent attachment-promoting behaviour in Attachment-Based Family Therapy for suicidal and depressed adolescents. Journal of Family Therapy, 38(1), 82–101. https://doi.org/10.1111/1467-6427.12078

Type of Study: Randomized controlled trial
Number of Participants: 19

Population:

  • Age — 13–18 years (Mean=15.5 years)
  • Race/Ethnicity — 58% African American, 26% European American, and 15% Biracial or Multiracial
  • Gender — 95% Female
  • Status — Participants were suicidal adolescents and their parents.

Location/Institution: Department of Psychiatry at the Children’s Hospital of Philadelphia

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same sample as Diamond et al. (2010). The purpose of the study was to examine whether the strength of the parent-therapist alliance, measured during the task of alliance building with parents alone, predicted the extent of parents’ attachment-promoting behavior in the subsequent conjoint parent-adolescent attachment task in the context of Attachment-Based Family Therapy (ABFT). Participants were randomly assigned to ABFT or to enhanced usual care. Measures utilized include the Vanderbilt Therapeutic Alliance Scale-Revised-Short Form (VTAS-R-SF), the Parental Attachment-Promoting Behaviour Scale (PAPBS), the Suicide Ideation Questionnaire-Jr. (SIQ-Jr), and the Beck Depression Inventory-II (BDI-II). Results indicate that the strength of the parent therapist alliance predicted parents’ subsequent attachment-promoting behavior. However, parents’ attachment-promoting behavior did not predict the posttreatment outcomes. Limitations include the small sample size, lack of generalizability due to characteristics of the population being sampled, lack of variance in outcome measures, and length of follow-up.

Length of controlled postintervention follow-up: None.

Ibrahim, M., Jin, B., Russon, J., Diamond, G., & Kobak, R. (2018). Predicting alliance for depressed and suicidal adolescents: The role of perceived attachment to mothers. Evidence-Based Practice in Child and Adolescent Mental Health, 3(1), 42–56. https://doi.org/10.1080/23794925.2018.1423893

Type of Study: Randomized controlled trial
Number of Participants: 115

Population:

  • Age — 13–18 years (Mean=14.96 years)
  • Race/Ethnicity — 49% African American, 29% White, 9% Multi-Racial, 7% Other, 2% American Indian/Alaskan Native/Native Hawaiian/Pacific Islander and 2% Asian
  • Gender — 82% Female and 18% Male
  • Status — Participants were adolescents with clinical levels of suicidal ideation.

Location/Institution: Philadelphia

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to investigate the efficacy of Attachment-Based Family Therapy (ABFT) with anxious or avoidant attachment to mothers or fathers as predictors of early formation of the therapeutic alliance in a high-risk sample of depressed and suicidal adolescents. Participants were randomly assigned to ABFT or to family-enhanced nondirective supportive therapy (FE-NST). Measures utilized include the Diagnostic Interview Schedule for Children, the Experiences in Close Relationships—Relationship Structures Questionnaire, the Suicide Ideation Questionnaire-Jr. (SIQ-Jr), the Beck Depression Inventory-II (BDI-II), and the Therapeutic Alliance Quality Scale (TAQS). Results indicate that there is a significant effect of perceived insecurity to mothers leading to lower levels of therapeutic alliance at Session 4. Limitations include insufficient data on therapist variables, reliance on self-reported measures, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Diamond, G. S., Kobak, R. R., Krauthamer Ewing, E. S., Levy, S. A., Herres, J. L., Russon, J. M., & Gallop, R. J. (2019). A randomized controlled trial: Attachment-based family and nondirective supportive treatments for youth who are suicidal. Journal of the American Academy of Child & Adolescent Psychiatry, 58(7), 721–731. https://doi.org/10.1016/j.jaac.2018.10.006

Type of Study: Randomized controlled trial
Number of Participants: 129

Population:

  • Age — 12–18 years
  • Race/Ethnicity — 50% African American, 29% White, 9% Other, 8% Bi-Racial or Multiracial, 2% American Indian/Alaskan Native, 2% Asian, and 1% Native Hawaiian/Pacific Islander
  • Gender — 82% Female
  • Status — Participants were adolescents with suicidal ideation and depressive symptoms.

Location/Institution: Philadelphia, Pennsylvania

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of Attachment-based Family Therapy (ABFT) compared to a family enhanced non-directive supportive therapy (FE-NST) for reducing adolescents’ suicide ideation and depressive symptoms. Participants were randomized to either ABFT or to FE-NST. Measures utilized include the Suicidal Ideation Questionnaire-Junior (SIQ-JR Monthly), the Beck Depression Inventory-II (BDI-II), the Columbia-Suicide Severity Rating Scale (C-SSRS), the Self-Report of Family Functioning (SRFF), and the Diagnostic Interview Schedule for Children (DISC). Results indicate that there was no significant between-group difference in the rate of change in self-reported ideation Suicidal Ideation Questionnaire-Jr. Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed significant reduction in suicide ideation. Adolescents receiving FE-NST experienced a similar significant reduction. Response rates (i.e. 50% or more reduction in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST. Limitations include a lack of reported follow-up and although nearly 70% of patients reported clinically significant change, only 40% obtained remission (non-clinical symptoms).

Length of controlled postintervention follow-up: None.

Russon, J., Abbott, C. H., Jin, B., Rivers, A. S., Winston‐Lindeboom, P., Kobak, R., & Diamond, G. S. (2023). Attachment‐Based Family Therapy versus nondirective supportive therapy for lesbian, gay, bisexual and questioning adolescents with depression, and suicidal ideation: An exploratory study. Suicide and Life‐Threatening Behavior, 53(6), 958–967.https://doi.org/10.1111/sltb.12995

Type of Study: Randomized controlled trial
Number of Participants: 129

Population:

  • Age — 12–18 years
  • Race/Ethnicity — 50% African American, 29% White, 9% Other, 8% Bi-Racial or Multiracial, 2% American Indian/Alaskan Native, 2% Asian, and 1% Native Hawaiian/Pacific Islander
  • Gender — 82% Female
  • Status — Participants were adolescents with suicidal ideation and depressive symptoms.

Location/Institution: Philadelphia, Pennsylvania

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same sample as Diamond et al. (2019). The purpose of the study was to determine the differential treatment effects and rates of change for lesbian, gay, bisexual, and questioning (LGBQ) and heterosexual adolescents with depression and suicidal ideation receiving either Attachment-based Family Therapy (ABFT) or family enhanced nondirective supportive therapy (FE-NST). Participants were randomized to either ABFT or to FE-NST. Measures utilized include the Suicidal Ideation Questionnaire-Junior (SIQ-JR Monthly), and the Beck Depression Inventory-II (BDI-II). Results indicate that LGBQ adolescents in the ABFT condition showed a greater rate of reduction in depressive symptoms over treatment than did LGBQ adolescents in the FE-NST condition. Heterosexual adolescents showed symptom reduction in both treatment conditions. Changes in suicidal ideation were found across time, but not across conditions. Limitations include concerns over expectancy bias due to therapists having access to measure results before seeing clients each session; less than half of the youth in the sample identified as LGBQ and the majority of these youth were in the ABFT condition making statistical power small; the majority of the LGBQ youth in the sample described themselves as being attracted to both males and females, therefore making findings more applicable youth who identify as bisexual or pansexual; and finally lack of follow-up.

Length of controlled postintervention follow-up: None.

Additional References

Ibrahim, M., Russon, J., & Diamond, G. (2017). Attachment-based family therapy for depressed and suicidal adolescents: Development, research and clinical practice. In U. Kumar (Ed.), Handbook of Suicidal Behaviour (pp. 505–521). https://doi.org/10.1007/978-981-10-4816-6_27

Krauthamer Ewing, E. S, Diamond, G. S, & Levy, S. (2015). Attachment-Based Family Therapy for depressed and suicidal adolescents: Theory, clinical model and empirical support. Attachment and Human Development, 17(2), 136–156. https://doi.org/10.1080/14616734.2015.1006384

Scott, S., Diamond, G. S., & Levy, S. A. (2016). Attachment-Based Family Therapy for suicidal adolescents: A case study. Australian & New Zealand Journal of Family Therapy, 37, 154–176. https://doi.org/10.1002/anzf.1149

Contact Information

Suzanne Levy, PhD
Agency/Affiliation: ABFT International Training Institute, LLC
Website: www.abftinternational.com
Email:
Phone: (267) 270-2245
Guy Diamond, PhD
Agency/Affiliation: ABFT International Training Institute, LLC
Website: www.abftinternational.com
Email:

Date Research Evidence Last Reviewed by CEBC: September 2024

Date Program Content Last Reviewed by Program Staff: March 2024

Date Program Originally Loaded onto CEBC: January 2020