Attachment‐Based Family Therapy: A Review of the Empirical Support

• DOI: http://doi.org/10.1111/famp.12241
• Author: Suzanne Levy,Guy Diamond,Jody Russon
• Published date: 01 September 2016
• Date: 01 September 2016

Attachment-Based Family Therapy: A Review of the

Empirical Support

GUY DIAMOND*

JODY RUSSON

†

SUZANNE LEVY

†

Attachment-based family therapy (ABFT) is an empirically supported treatment

designed to capitalize on the innate, biological desire for meaningful and secure relation-

ships. The therapy is grounded in attachment theory and provides an interpersonal, pro-

cess-oriented, trauma-focused approach to treating adolescent depression, suicidality, and

trauma. Although a process-oriented therapy, ABFT offers a clear structure and road map

to help therapists quickly address attachment ruptures that lie at the core of family conflict.

Several clinical trials and process studies have demonstrated empirical support for the

model and its proposed mechanism of change. This article provides an overview of the

clinical model and the existing empirical support for ABFT.

Keywords: Attachment-Based Family Therapy; Adolescents; Depression; Suicidal

Ideation; Research

Fam Proc 55:595–610, 2016

INTRODUCTION

The mechanical-based model of cybernetics and the biological-based model of general

systems theory pushed us to look beyond intrapsychic processes for sources of illness

and strength. These theories, however, did not provide a clinically meaningful framework

for understanding the interpersonal and emotional motivations that drive the quality of

family relationships. In contrast, Attachment Theory (Bowlby, 1969) describes how the

life-long interactions between individual needs and relational experiences determine the

quality of family life and individual development. For Bowlby, what happens in relation-

ships shape one’s internal working model or expectations of self and other. These models

in turn influence how individuals behave in relationships; a transactional process that

continues throughout the life span.

Attachment theory also provides a model for understanding therapeutic change. The

theory proposes that psychological growth results from a mixture of improving self-reflec-

tion and self-understanding combined with promoting new, more positive, experiences in

actual relationships. Given this interactional model of change, many individual and family

therapists have turned to attachment theory to describe the therapeutic process (Dia-

mond, Diamond, & Levy, 2014; Fosha, 2000; Hughes, 2007; Johnson, 2004; Lieberman,

2004; Solomon & Siegel, 2003; Young, Klosko, & Weishaar, 2003). In individual therapy,

however, the therapist serves as the secure base—the “good parent” who resuscitat es the

*Couple and Family Therapy, Drexel University, Philadelphia, PA.

†

Drexel University College of Nursing and Health Professions, Philadelphia, PA.

Correspondence concerning this article should be addressed to Jody Russon, Drexel University College

of Nursing and Health Professions, 3020 Market St. Suite 510, Philadelphia, PA 19104.

E-mail: jmr439@drexel.edu.

595

Family Process, Vol. 55, No. 3, 2016 ©2016 Family Process Institute

doi: 10.1111/famp.12241

patient’s trust in others and confidence in oneself. However, the individual therapist’s

empathic and consoling statement of “it is not your fault” pales in comparison to the vali-

dation a child receives when the parent says, “it was not your fault.” In family therapy,

the actual family members sit in the room together with the opportunity for each person

to better understand and change their role in the family process. Therefore, from an

attachment perspective, individual and relational change occurs through the restoration

or refurbishing of healthy, trustworthy, reliable, and emotionally sensitive parent–child

relationships (Kobak & Sceery, 1988).

Attachment-based family therapy (ABFT; Diamond et al., 2014) capitalizes on the

innate, biological, and existential desire for meaningful and secure relationships. There-

fore, we do not start therapy with problem solving or behavioral management. Instead,

like emotion-focused couples therapy (Johnson, 2004), we work to uncover what experi-

ences (e.g., abuse) and relational processes (e.g., harsh criticism) have damaged trust in

family relationships. We uncover these “traumas” and help the family have an authentic,

honest, emotionally engaged, and regulated conversation about these relational disap-

pointments. Topics might include varying degrees of abuse, neglect, abandonment, or life

circumstances like divorce, parental depression, or loss. At one level, these conversations

help individuals resolve or work through these traumas. At another level, these conversa-

tions provide an opportunity for adolescents and parents to practice newly learned rela-

tional skills. At a third level, this conversation enacts a corrective attachment experience:

children express vulnerable thoughts and feelings and parents remain available, respon-

sive, and emotionally attuned. Engineering these attachment-promoting conversations

improves views and expectations of self and others, which, in turn, impacts how family

members interact together.

Thus, we developed ABFT to explicitly target the improvement of attachment security

as the primary mechanism of change. Still, ABFT is rooted in four family-based clinical

traditions. From structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981),

we rely on the concept of enactment. These in-session, in vivo experiences of change con-

solidate psychological and interpersonal learning. From multidimensional family therapy

(Liddle, 2010), we borrow the framework of using psychological science to inform the selec-

tion of treatment targets and our understanding of how to facilitate the therapeutic pro-

cess. From emotion-focused individual (Greenberg & Paivio, 2003) and couples therapy

(Johnson, 2004), we incorporate a focus on emotions as a key ingredient of therapeutic

change. Finally, from contextual therapy (Boszormenyi-Nagy & Krasner, 2013), we bor-

row the concept of trust as the basic fabric of family life, without which behavioral and

interpersonal problem solving will fail.

Attachment theory, however, provides the primary theoretical and clinical framework

of ABFT. Attachment theory posits that when parents are sensitive and availa ble, chil-

dren grow up with the confidence that parents will support and protect them, while also

feeling worthy of being loved and protected. From these trustworthy relationships, chil-

dren also learn to regulate their emotions. For instance, children use parents to soothe

their anxieties and fears, thus learning to down regulate negative affect and to feel com-

fortable expressing vulnerable emotions. Over time, children begin to internalize these

relational expectations as internal working models, setting the foundation for what they

will expect from others in future relationships.

The role of secure attachment is no less important in adolescence. Rather than separa-

tion and individuation (e.g., Erikson, 1968), the central task of adolescence i s to maintain

attachment while negotiating autonomy. Adolescents who keep this balance do better in

school, have fewer deviant peer relationships, and even have better health outcomes

(Allen, Moeller, Rhoades, & Cherek, 1998; Kobak, Cassidy, Lyons-Ruth, & Ziv, 2006;

Lynch & Cicchetti, 1991; Rosenstein & Horowitz, 1996). When adolescents do not have a

www.FamilyProcess.org

596

/

FAMILY PROCESS