Programs that Work
Attachment-Based Family Therapy
Healthy and Safe Children
Children not experiencing anxiety or mood disorders, such as depression
Age of Child
Type of Setting
Health Care Provider
Type of Service
Health Care Services
Type of Outcome Addressed
Evidence Level (What does this mean?)
Attachment-Based Family Therapy (ABFT) is based on the belief that strong relationships within families can buffer against the risk of adolescent depression or suicide and help in the recovery process. ABFT is a psychotherapeutic model, with a foundation in attachment theory. Attachment theory posits that when parents are responsive and protective, children develop a healthy sense of self, trust in others, and better capacity for independence and affect regulation. Ruptures in attachment security can increase the risk for psychopathology. However, as a life-span developmental model, attachment theory posits that attachment ruptures are reparable, and thus children can regain the external and internal resources to promote healthy development.
The ABFT model aims to strengthen or rebuild secure parent-child relationships and promote adolescent autonomy. To accomplish this, the therapist helps the family agree to focus on relationship repair as the initial goal of therapy. Then, with the adolescent alone, the therapist helps the adolescent identify perceived attachment ruptures or negative family processes and prepares the adolescent to talk about these problems with his or her parents. In separate sessions with parents, the therapist focuses on reducing parental distress and improving parenting practices. Exploring their own history of attachment rupture helps parents understand their own attachment wounds and builds empathy for the adolescent. When ready, conjoint sessions focus on helping the family successfully discuss these past problems. This process both helps resolve actual problems in the family and allows parents and adolescents to practice new skills related to affect regulation and interpersonal problem solving. As trust begins to reemerge, therapy focuses on promoting adolescent competency outside the home.
Depressed adolescents and their families
Two trials have examined the impact of ABFT. The first study, published in 2002, was conducted among adolescents referred to treatment by their schools or their parents who met the Diagnostic and Statistical Manual IIIóRevised (DSM-IIIR) criteria for Major Depressive Disorder (MDD). The adolescents were between the ages of 13 and 17, with a mean age of 14.9 years old. Eighty percent of the adolescents in the trial came from single-parent homes, and 69 percent came from households with annual incomes of less than $30,000. Forty-seven percent of adolescents had heard random gunshots in the past six months, 31 percent had family members who used drugs or alcohol, and 19 percent had had unwanted sexual experiences. To enter into the study, adolescents and their parents were required to be willing to participate, and adolescents had to meet the DSM criteria for MDD and not have psychotic symptoms (Diamond et al., 2002).
Eligible adolescents and their families were randomly assigned to the 12-week ABFT intervention (16 participants) or a six-week waitlist control (16 participants). The groups were not statistically significantly different in demographics or baseline measures of depression. Adolescents who were assigned to the waitlist were given weekly 15-minute phone calls restricted to monitoring for deterioration in depressive symptoms. Adolescents on the waitlist were entered into ABFT six weeks after the commencement of the treatment, because it was deemed unethical to withhold treatment from this group for longer than six weeks. ABFT, however, is a 12-week program; thus, it is only possible to test for differences in the outcomes for the waitlist control group with those of the ABFT group at six weeks, one-half of the full duration of ABFT. The authors report the ABFT 12-week outcomes for both groups as well.
The Diamond et al. (2002) study examined the following outcomes:
- Depression, as measured by the Beck Depression Inventory (BDI), a self-reported tool
- Family Functioning, as measured by the Self-Report of Family Functioning, a self-reported measure collected among the adolescents themselves, not among their parents or other family members.
The second Diamond et al. study, published in 2010, examined the effects of ABFT among suicidal adolescents between the ages of 12 and 17. Participants were identified in primary care and emergency departments. Referred adolescents were not eligible for participation if they needed psychiatric hospitalization, were recently discharged from a psychiatric hospital, had current psychosis, or had mental retardation or a history of borderline intellectual functioning. Of 341 adolescents screened, 66 entered the study. Of the 66 who entered the study, 35 were randomly assigned to ABFT and 31 were assigned to the control group, in which they received "enhanced usual care," including a referral to other providers for treatment and weekly check-in phone calls monitoring for deteriorating depression and increased suicidal ideation. Among the 31 adolescents receiving "enhanced usual care" instead of ABFT, 52 percent were referred to and received individual therapy, 19 percent received group therapy, 6 percent received family therapy, 3 percent received case management, and 19 percent did not attend any treatment. The treatment and control groups were not statistically significantly different in demographics or clinical variables prior to treatment.
The Diamond et al. (2010) study examined the following outcomes:
- Suicidal ideation, as measured by the Suicidal Ideation Questionnaire, Junior High version (SIQ-JR), a self-reported measure, and the Scale for Suicidal Ideation (SSI), an assessor-administered tool
- Depression, as measured by the Beck Depression Inventory (BDI)
Key Evaluation Findings
In Diamond et al. (2002), adolescents undergoing six weeks of ABFT had a lower prevalence of clinically significant depression (56 percent), defined as a score on the BDI of greater than 9, than did their control group counterparts (19 percent). There were no significant effects of six weeks of the program on adolescent self-report of family functioning as measured by the Self-Report of Family Functioning. Note that the observed effects only demonstrate the impact of ABFT at mid-treatment, prior to the control group entering treatment.
The 2010 trial conducted among suicidal adolescents (Diamond et al., 2010) found that ABFT participants improved on several measures of suicidality compared with the control group:
- The ABFT group showed greater improvement on self-reported suicidal ideation (SIQ-R) at the conclusion of the program and at the follow-up administered Scale for Suicidal Ideation (SSI) at 12 weeks after the program's conclusion. At the treatment's conclusion, 87 percent of ABFT participants and 51 percent of control-group participants reported suicidal ideation in the normal range, and at the follow-up 12 weeks post-treatment, these numbers were 70 percent and 34 percent, respectively.
- Clinical recovery on an assessor-administered suicidal ideation scale (SSI) was greater in the ABFT group at the conclusion of the program and at follow-up. In particular, at the program's conclusion, 69 percent of ABFT participants and 34 percent of control-group participants reported no suicidal ideation in the past week. Twelve weeks after the program's conclusion, these gains continued, with 82 percent of ABFT participants and 46 percent of control group participants reporting no suicidal ideation in the past week.
- Four ABFT participants and seven control group participants made low-lethality suicide attempts during the course of treatment, but these numbers are too small for statistical significance analyses.
In addition to the above measures related to suicidality, fewer ABFT participants had clinically significant depression at the end of treatment (34 percent versus 11 percent). This improvement in the ABFT group relative to the control group was only marginally significant, however, and statistically significant improvements on clinically significant depression did not persist into the 12-week post-treatment follow-up.
Therapists working with adolescents at risk for depression or suicide
Grants for evidence-based mental health treatment may be available from federal and local funding sources, including the Substance Abuse and Mental Health Services Administration (www.samhsa.gov) and the National Institute of Mental Health (www.nimh.gov).
ABFT treatment has five specific tasks, each of which takes from one to three sessions to accomplish:
- Relational reframe task: Refocuses the family away from "fixing" the patient toward building better relationships within the family.
- Adolescent alliance-building task: Focuses on building a bond between therapist and adolescent, identifying core family dynamics that inhibit the parent-child relationship, and encouraging youth to discuss these issues.
- Parent alliance-building task: Focuses on reducing parental distress and improving parenting practices. It begins with an exploration of the parents' stressors and their own history of attachment failures, with the goal of improving empathy toward the adolescent and making parents more receptive to coaching.
- Reattachment task: Adolescents explore past and present experiences, thoughts, and feelings that have violated the attachment bond and damaged trust with caregivers. Parents are coached to provide an empathic, supportive stance so that adolescents can explore and express cognitive, emotional responses to these events. This corrective attachment experience helps adolescents begin to reevaluate their internal working models of self and other and promotes change in the interactions between family members.
- Competency-promoting task: Family members are encouraged to continue practicing improved communication skills while fostering the adolescent's success and connections outside of the home. This helps promote appropriate adolescent autonomy while maintaining the parent-child connection.
ABFT can be delivered by therapists who have the minimum qualifications of a master's degree in social work or equivalent. Certification in ABFT is offered by staff of the Children's Hospital of Philadelphia, either on-site at the hospital or off-site at the agencies themselves. Certification generally occurs over a two-year period and includes two three-day workshops and bi-weekly 90-minute group case consultation calls, video supervision, and individual feedback. Therapists must meet fidelity standards to be credentialed. When working with an agency, at least two therapists and a clinical supervisor need to participate.
Therapists or agencies interested in discussing credentialing procedures and locations for certification should contact Dr. Guy Diamond or Dr. Suzanne Levy (see contact information).
ABFT has a treatment manual that provides a roadmap to the treatment tasks documented above.
Issues to Consider
This program received a "Proven" rating. Both of the evaluations cited used a randomized controlled trial design, which is considered the "gold standard" evaluation methodology. The evaluation published in 2002 included only 16 adolescents in each of the control and treatment groups, which does not meet the PPN "Proven" criteria, but the evaluation published in 2010, which included more than 30 adolescents in each group, does meet the standard. The cited evaluations were both lead-authored by the ABFT developer.
Both of the studies cited in this summary were conducted among a specific subset of the population of depressed adolescents. Diamond et al. (2002) was conducted among depressed adolescents at higher risk than the general population based on socioeconomic status. Diamond et al. (2010) was conducted among suicidal adolescents, who experience more severe depression than the general population of depressed adolescents. Thus, the findings of these studies must not be assumed to be generalizable to the population of depressed adolescents at large.
ABFT has been implemented by therapists in a number of agencies nationwide and internationally.
Guy Diamond Ph.D.
Director, The Center for Family Intervention Science
The Children's Hospital of Philadelphia
3535 Market St. Suite 1230
Philadelphia, PA 19104
Suzanne Levy Ph.D.
Training Director, The Center for Family Intervention Science
The Children's Hospital of Philadelphia
3535 Market St. Suite 1230
Philadelphia, PA 19104
For more information on how to implement ABFT, visit:
Guy S. Diamond, Brendali F. Reis, Gary M. Diamond, Lynne Siqueland, and Lisa Isaacs, "Attachment-Based Family Therapy for Depressed Adolescents: A Treatment Development Study,"
Journal of the American Academy of Child and Adolescent Psychiatry,
Vol. 41, No. 10, October 2002, pp. 1190-1196.
Guy S. Diamond, Lynne Siqueland, and Gary M. Diamond, "Attachment-Based Family Therapy for Depressed Adolescents: Programmatic Treatment Development," Clinical Child and Family Psychology Review, Vol. 6, No. 2, June 2003, pp. 107-127.
Guy S. Diamond, Matthew B. Wintersteen, Gregory K. Brown, Gary M. Diamond, Robert Gallop, Karni Shelef, and Suzanne Levy, "Attachment-Based Family Therapy for Adolescents with Suicidal Ideation: A Randomized Controlled Trial," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 49, No. 2, February 2010, pp. 122-131.