Nearly 20% of adolescents and young adults seriously consider ending their own life.1 Having a patient die by suicide is one of the things most feared by health care providers.2 Whether or not medical and other health professionals will encounter a suicidal adolescent while working with youth is not really a question of if, but of when. When medical personnel encounter suicidal adolescents, whether in the emergency department, clinic setting, or primary care office, the initial action to protect the patient is usually hospitalization.
The availability of inpatient adolescent psychiatric beds is usually the barrier to this initial treatment. The inpatient setting, which is usually for only a few days, is a safe place where stabilization can occur. Often, initial follow-up treatment upon discharge is provided and includes an appointment with an outpatient therapist and a psychiatrist (if medication is part of the treatment plan). Treatment for these suicidal adolescents is often focused on attempting to decrease symptoms of depression through coping skills and possibly medication. These treatments are provided in individual sessions or in brief visits regarding medication. What is not often included is the patient's family and the system within which the adolescent currently lives.
A growing body of research has established a link between several key family factors (parental criticism, emotional unresponsiveness, lack of support, lack of care, experienced rejection, perceptions of burdensomeness, and control) and suicide attempts or ideation.3 Suicide ideation and attempts have also been identified as having higher frequency in families with low levels of cohesion and high levels of conflict.4,5 Although many family factors function as risk factors for suicide, they can also function as protective factors.
Family cohesion has been shown to protect against suicide-related thoughts and behaviors.6,7 Adolescents who describe their parents as being involved and showing high levels of shared interests or emotional support were shown to be 3 to 5 times less likely to be suicidal than peers from less supportive families.7 Supportive parent-child relationships and parental monitoring (not control) have been associated with fewer suicide-related thoughts and behaviors, depression, and better overall functioning.8,9 As the connection between family factors and adolescent suicide-related thoughts and behaviors is becoming more well known, more recommendations are being made to include family in the treatment.10
One promising treatment developed specifically for addressing adolescent depression and suicide is attachment-based family therapy (ABFT).11–15 ABFT is a brief, manualized, family-based treatment and is listed on the National Registry of Evidence-based Programs and Practices. ABFT is an emotion-focused, client-respectful (not client-focused), relational intervention. This article provides a brief review of the model, its clinical application, and empirical support.
Theoretical Foundation of Attachment-Based Family Therapy
The ABFT model is grounded in attachment theory.16 One of the primary precepts of attachment theory is that children are biologically hard-wired to seek comfort and support from parents when distressed. Part of the ABFT belief is that insecure attachment to parents or caregivers can exacerbate (but not necessarily cause) the symptoms of depression and suicide-related thoughts and behaviors.17
ABFT also has a strong clinical foundation on structural family therapy, multidimensional family therapy, and emotion-focused therapy approaches.18–20 The treatment goals are also informed by recent adolescent and parenting development theories.21–24 The ABFT stance is that the development of more secure attachments with parents will allow the adolescent to turn to parents when in distress and in need of comfort. Although learning to cope with strong and disturbing emotion is an aspect of ABFT, the central focus is on the improvement of family relationships as the mechanism that will help reduce feelings of depression and suicidality.25–27
Task 1: The Relational Reframe
The overarching goal of the first session (task 1) is to reframe the problem relationally. This involves joining with the family, fact finding, understanding the context or history of the depression, and beginning to identify relational ruptures. The ABFT model assumes there is some reason that a depressed or suicidal adolescent does not turn to their parents when in distress and need—this is the essence of the relational rupture to understand. The purpose of this reframe is to shift the family's focus from the problem of adolescent depression and suicidality to being willing to work on improving the family relationship. Ultimately, the first task is successful when the family (adolescent and parent) are willing to come back for another session. It is important to have a systemic perspective in mind and focus on the relationship quality.28
Task 2: Adolescent Alliance
In the second task, the goal is to bond and develop a therapeutic alliance with the adolescent. The adolescent, thus, is typically seen individually. This task initially focuses on developing an understanding of how the adolescent felt about the relational reframe task. The task then focuses on developing further understanding about treatment and what confidentiality means in relation to the individual and family sessions that will be occurring. The task also focuses on developing a systemic treatment plan and helping the adolescent feel comfortable bringing up core conflicts with the parent(s).28
One of the main goals of the adolescent alliance task is to develop an attachment narrative. This narrative is developed through trying to understand how the adolescent's attachment experiences have shaped their beliefs about themselves and their parents primarily. The ABFT model assumes that if a child experiences a parent as unresponsive or critical during times of distress and need, the child will start to expect the parent to not be a source of comfort and safety. 28
Essentially, the treatment team works to develop a belief that the adolescent has the right to turn to parents when in need. It also develops the belief that parents have a responsibility to help the child when in need. In a way, task two is strategic and validates the adolescent's feeling of being abandoned or not good enough.28
Once an alliance has been developed, the depression is more understood and attachment ruptures have been identified, the task shifts to connecting the depression and thoughts of suicide to the attachment ruptures. The ABFT model does not view the relational ruptures as the cause of the depression (but that can be the case). Instead, the relational rupture is viewed as one of the things preventing the adolescent from getting better. As a connection between the attachment ruptures and the depression is solidified, the therapist then begins to explore thoughts, fears, and hopes about resolving some of the feelings about the attachment ruptures and how being able to talk about the depression will likely help to alleviate some of the pain.28
Task 3: Parent Alliance
The third task, parent alliance, typically occurs with parents only. The task begins with a focus on building a therapeutic alliance with the parents and understanding the context of the parents' life. Therapists may explore differenced in parenting styles between parents, current stressors, and the parents' own attachment history. Sometimes, it becomes apparent that changes to parenting styles may be needed. The discussions focus on how current parenting affects the parent-child relationship and may be connected to the adolescents' unwillingness to use the parents as a resource.28
Exploring the parents' intergenerational history is an integral aspect of this process. Parents are able to see how their own attachment history has influenced their parenting styles. Once parents are able to develop some self-empathy for their experiences as children, they are better situated to begin to understand and empathize with their child. This involves expanding the parents' narratives about themselves, their child, and their familial interactions. Having this empathy and being willing to look at their patterns more objectively helps the parents to see and be accountable for their own contributions to the patterns of behavior.28
This task prepares the parents to be emotionally tuned with one another and their adolescent child while having some difficult conversations. Although psychoeducation about depression, suicide, and other relevant parenting topics does occur, the bulk of this task is about developing a sincere motivation to change. This task involves helping the parents improve their ability to listen, to be curious about, and to empathize with challenges their child is facing. Many parents are hesitant to change their parenting style because they fear that this will also mean they are abandoning other deeply held beliefs about family roles, rules, and expectations (ie, cultural and religious beliefs). Although the discussion about new parenting styles and parenting tactics does often involve practicing new emotion coaching and listening skills, the point is to help the parents be sources of comfort and support for their child.28
Task 4: Repairing Attachment
The repairing attachment task has three phases designed to provide a corrective attachment experience between the adolescent and parent(s). The first phase is the adolescent disclosure to the parents about their experience of the attachment ruptures and unmet attachment needs. The parents have been primed, and are coached, to show more emotional attunement, which will encourage the adolescent to challenge their expectations of critical, negative, or neglectful responses from parents. The adolescent, who has also been primed and coached to speak about these difficult topics, is able to demonstrate more maturity and less fragility by engaging in a discussion in a more direct and regulated manner. The second phase is the parent disclosure in which the parent apologizes (if appropriate) or shares their experience of the attachment rupture. Although the first phase focuses primarily on the parents listening to the adolescent, this second phase is about how the parents engage and respond. If all family members are engaged and believe what is being said, the task is working as planned. The third phase occurs after both child and parent have shared their experiences of the attachment rupture(s) and believe they have been heard and that they have listened to understand the experience of the other. This process can be repeated as much as needed.28
Task 5: Promoting Autonomy
After having addressed the existing ruptures, the treatment shifts to promoting autonomy and solidifying changes in the relationship that were gained during the repairing attachment task. Task 5 has three main goals: (1) to increase both the quality and the content of experiences that promote competency; (2) to increase connection between the adolescent and other family members, friends, or any other resource; and (3) to help the parents become more effective resources for the adolescent.28
The goal for this task is to have the treatment provider, parents, and any other person important to the process (cousin/friend/mentor/teacher) be involved in assisting the adolescent to develop the ability to be more resilient and effective. This task needs to address the adolescent at their developmental level. Problem-solving discussions are often appropriate at this point. This process will look very different for a 13-year-old in middle-school compared with an 18-year-old about to attend college. Essentially, task 5 is designed to help the family and adolescent prepare to continue on without ABFT.28
Working with suicidal adolescents is challenging. Available treatments beyond a crisis psychiatric admission for safety and stabilization take time and often attempt to assist by addressing the adolescent individually. It is not uncommon for adolescents with a history of depression and suicide-related thoughts and behaviors to view themselves as broken and being fundamentally flawed or unwanted. This is often exacerbated through interactions with mental health professionals, hospitalizations, and countless treatments. Although creating safety and means-restrictions are essential to working with suicidal adolescents, helping the adolescent to feel emotionally safe and loved at home can and does provide relief as well. ABFT is difficult and emotional work. There are cases in which this treatment would neither be appropriate nor sufficient. However, we believe that parents are in the best position to understand, connect with, and support their children. ABFT attempts to recreate, strengthen, and use the attachment between parents and adolescents as the base from which the adolescent will recuperate.
- Center for Disease Control & Prevention. National Center for Injury Prevention and Control. Suicide: facts at a glance 2015. https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed July 7, 2017.
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