A
Attachment-Based Family
Therapy
Guy Diamond, Jody Russon and Suzanne Levy
Center for Family Intervention, Drexel
University, Philadelphia, PA, USA
Name of Model
Attachment-Based Family Therapy
Introduction
Attachment-based family therapy (ABFT;
Diamond et al. 2014) is a trust-based, emotion-
focused, empirically supported treatment that
aims to repair interpersonal ruptures and rebuild
secure, protective caregiver-child relationships.
ABFT is designed to improve the family’s capac-
ity for affect regulation, relational organization,
and problem solving. This strengthens family
cohesion, which can buffer against depression,
suicidal thinking, and risk behaviors (Restifo and
Bogels 2009). This framework is particularly rel-
evant to adolescents for whom the family context
is inescapable (Maccoby and Martin 1983).
ABFT is rooted in structural family therapy, multi-
dimensional family therapy, emotionally focused
therapy, and contextual family therapy. The
ABFT manual is interpersonal and process-
focused, but offers a structure and roadmap for
# Springer International Publishing AG 2018
J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy,
https://doi.org/10.1007/978-3-319-15877-8_158-1
how to facilitate depth-oriented therapy in a 12 to
16 week period. The model unfolds in five dis-
tinct, but interrelated, treatment tasks that focus on
critical treatment processes. These tasks serve as a
guide for helping the family to repair attachment
ruptures and work toward increasing trust and
security.
Prominent Associated Figures
Guy Diamond, Ph.D.
Gary Diamond, Ph.D.
Suzanne Levy, Ph.D.
Theory
ABFT is a brief family-based therapy with a solid
grounding in attachment theory (Bowlby 1969).
This theory proposes that when children are dis-
tressed, they are “hard-wired” to seek support and
comfort from their parents. When children expe-
rience their parents as responsive and available in
the face of distress, they begin to feel that (a) the
world is a safe place and (b) they are worthy of
being loved protected. Over time, these experi-
ences of protection become internalized as work-
ing models (or expectations) of relationships. If a
child is treated well, then they seek out similar
relationships. When a child is treated poorly, they
internalize expectations that their relationships
will be unresponsive, if not hurtful. In the face of
2 Attachment-Based Family Therapy
these untrustworthy relationships, children
develop attachment (interpersonal) strategies that
will protect them from more harm: dismissive,
preoccupied, or disorganized.
If internal working models are shaped by real
relationships, then these real relationships can
revise internal working models and other behav-
ioral changes. ABFT aims to revive the adoles-
cent’s hope for attachment security and promote
responsive parenting. Improving the family’s
communication, problem-solving, and emotional
regulation can create the corrective attachment
experiences that help adolescents work through
past traumas and relational ruptures. This estab-
lishes the groundwork for rebuilding secure rela-
tionships with parents.
Strategies and Techniques Used in ABFT
In ABFT, the “corrective attachment experience,”
and subsequent autonomy building, is engineered
using five distinct treatment tasks. Tasks are not
equated with sessions. Instead, a task is a set of
procedures, processes, and goals related to resolv-
ing or accomplishing specific aims in therapy
(e.g., building alliance). Task I offers a roadmap
for establishing an essential and common process
inherent to many family therapy models: getting
the family members to agree to work on relation-
ship building rather than behavioral management.
To achieve this, the therapist focuses on resusci-
tating the adolescent’s desire for protection and
support as well as the caregivers’ longing for love
and connection with their child. The therapist pro-
motes the caregivers as “the medicine” to help the
adolescent cope with, and recover from, depres-
sion and suicidal ideation.
Task II consists of individual sessions with the
adolescent. The therapist aims to help adolescents
identify and articulate their perceived experiences
of caregivers’ attachment failures and prepare
them to discuss these felt injustices in Task
IV. Task III consists of individual sessions with
the caregivers. The therapist aims to help each
caregiver consider how their own life stressors
and intergenerational legacies of attachment rup-
tures affect their parenting style. This insight
helps caregivers develop greater empathy for
their adolescent’s experiences. With this insight,
caregivers become more motivated to learn new
emotion coaching and parenting skills.
Next, in Task IV, the therapist brings the ado-
lescent and caregivers back together to discuss
and understand how these relational disappoint-
ments have damaged trust in the relationship. As
adolescents share these thoughts, feelings, and
memories and receive acknowledgment and
empathy from their caregivers, they become
more willing to consider their own contributions
to family conflicts. As caregivers acknowledge
adolescents’ experiences, adolescents become
more emotionally regulated and cooperative.
Although these conversations may not address or
resolve all relational problems, this mutually
respectful, and often emotionally profound, dia-
logue serves as a “corrective attachment experi-
ence,” thus revising the adolescent’s internal
working model of self and other. In this new
emotional climate, caregivers become a resource
and secure base for their adolescent. Task V then
focuses on using the caregiver to support the
adolescent’s exploration of competency and
autonomy. Adolescents begin to seek comfort,
advice, support, and encouragement from their
caregivers while exploring new opportunities
and managing life stressors. Table 1 summarizes
the treatment targets and expected outcomes for
each of these five treatment tasks.
Populations in Focus
ABFT is a therapy for adolescent depression and
suicide; however, youth with other presenting
problems can benefit from the clinical model.
ABFT has been useful for clients with histories
of trauma, eating disorders, substance use, or vic-
timization due to their sexual identity (see full
review in Diamond et al. 2016a). ABFT is flexible
enough to incorporate comorbid conditions and
has gained empirical support for young adults
with unresolved anger toward a caregiver
(Diamond et al. 2016b).
Low income, minority families have been
absent from many of the clinical trials testing
Attachment-Based Family Therapy 3

Attachment-Based Family Therapy, Table 1 Targeted risk factors, relevant treatment task, and expected
outcomes. Adapted from Diamond et al. (2003)
Treatment targets
Caregiver criticism and
blame
Adolescent hopelessness
about, and disengagement
from, caregiver
Caregiver stress and
abdication
Adolescent-caregiver
disengagement and conflict
Poor adolescent functioning
in extra-familial contexts
Interventions
Relational reframe
Alliance building with
adolescent
Alliance building with
caregivers
Repairing attachment
Promote caregiver support for
adolescent competency and
autonomy
Expected outcomes
Caregivers and adolescent become more willing to
focus on relationship building instead of behavior
management
Build treatment bond with adolescent, help them
understand their attachment rupture narrative, and
prepare them to discuss these stories with their
caregivers in task IV
Build treatment bonds with caregivers, increase
caregiver awareness of adolescent’s attachment
needs, and teach parenting skills that will promote
attachment-repairing conversations in task IV
Increase adolescent’s perceptions of caregivers’
availability and protection, increase adolescent’s
confidence in communicating his or her needs, build
caregivers’ view of their adolescent as having
legitimate concerns (who can express themselves in
a direct and emotionally regulated manner), work
through memories of loss and abuse, and improve
interpersonal and conflict resolution skills
Increase adolescent’s use of the caregivers as a
secure base for problem solving and identity
development

psychotherapies for youth depression and suicide
(Bernal et al. 2009). ABFT, however, has had a
history of success working with diverse families.
In general, ABFT is recommended for clients
12 years of age and older and is not limited by
treatment context. The model has been used in
outpatient, inpatient, home-based, hospital set-
tings, and residential care. ABFT is not
recommended as a treatment approach for clients
with active psychosis, low-functioning autism
spectrum disorders, borderline intellectual func-
tioning, or severe externalizing behaviors. How-
ever, the guiding principles and tasks of ABFT can
be applied when working with any family.
Empirical Support
ABFT research is conducted at the Center for
Family Intervention Science (CFIS) at Drexel
University and at partnering sites throughout the
world (Diamond et al. 2016a). ABFT research has
focused primarily on reducing depression and sui-
cide in adolescents, ages 12 to 18. To date, several
studies have been conducted demonstrating the
efficacy of ABFT. These studies have shown that
ABFT is more effective than waitlist control
groups or treatment as usual in reducing depres-
sion and suicidal ideation. ABFT has also been
adapted for use with suicidal LGB adolescents
(Diamond et al. 2012). Secondary data analysis
indicates that ABFT is effective for severely
depressed adolescents and those with a history of
sexual abuse, both predictors of poor response in
treatment with combined medication and cogni-
tive behavioral therapy (Asarnow et al. 2009;
Barbe et al. 2004). Also several process studies
have explored the proposed mechanisms of
change (see Diamond et al. 2016a for a review).
A new study comparing ABFT to Family-
Enhanced Non-Directive Supportive Therapy
has just been completed. Results are not yet avail-
able, but seem very promising.
Several effectiveness research projects have
been conducted or are currently underway. Israel
and Diamond (2013) explored the feasibility of
training therapists to conduct ABFT in a hospital
setting in Norway. Similar implementation
4 Attachment-Based Family Therapy
challenges are explored in three recent papers on
implementing ABFT in Australia (Diamond et al.
2016c), Belgium (Santens et al. 2016), and Swe-
den (Ringborg 2016). In the United States, we
have recently partnered with an LGBTQI youth
center to conduct an implementation study of
ABFT in a community counseling center working
with this population. This empirical support
reviewed above meets the criteria for a promising
intervention (Chambless and Hollon 1998) and
ABFT is currently listed on the National Registry
of Evidence-based Programs and Practices
(NREPP).
Case Study
Brittney was a 17 year old, African American, and
Caucasian (biracial) adolescent who lived with
her mother, Sharise, and younger brother. The
father lived in the home until Brittney was nine;
however, he was not involved in her life at the
time of this therapy. The family was referred from
a local inpatient psychiatric hospital after treat-
ment for severe suicidal ideation. Brittney strug-
gled throughout her life socially and
academically. Although very creative, athletic,
and intelligent, Brittney reported difficulties
“fitting in” and being bullied given her biracial
identity. She discussed how she felt “not black
enough.” These issues with peers impacted her
ability to attend school.
Sharise self-identified as African American
and came to therapy with concerns about her
daughter’s suicidal ideation, depression, anger,
and “out of control” sexual behavior. Specifically,
Sharise had recently “caught” her daughter
kissing “an older guy” outside of her school.
Sharise described her daughter as being highly
susceptible to peer influence (e.g., cutting class
to hang out with friends, provoking fistfights in
school, and staying out past curfew). Sharise
reported no history of family mental health con-
cerns, but described a history of domestic violence
in several of her past romantic relationships and
between her own parents in childhood. At the time
of treatment, Sharise had a steady job and was
single.
Brittney and Sharise attended ABFT sessions
for 4 months. Sessions were focused on repairing
ruptures between mother and daughter. The pri-
mary ruptures involved Brittney’s feelings of
“being attacked” by her mom when she tried to
share feelings about being bullied at school, feel-
ing rejected by her father, and feeling abandoned
by her mom during episodes of domestic violence
between Sharise and her previous partners. After
trust was rebuilt between mother and daughter,
sessions focused on being bullied, school strug-
gles, career goals, identity development (e.g.,
what it means to be a biracial woman), and
sexuality.
Task I: Relational Reframe. Initially the ther-
apist joined with Sharise around her concerns
about her daughter’s depression, sexual behavior,
and peer relationships. She also joined with
Brittney around her depression which resulted
from being bullied, feeling rejected by her father,
and feeling as though she did not “fit in” given her
biracial identity. The primary focus of the Rela-
tional Reframe was captured in the following
question: “When you feel so bad that you want
to hurt yourself, why don’t you go to your mother
for help?” In response, Brittney disclosed that she
worries about her mom’s negative opinions of her
and does not want to stress and burden her mother.
Brittney expressed that, in the past, she had felt
more comfortable talking to her few close friends
and boyfriend; however, with her recent struggles
with peers, she felt completely “alone.” At first,
Sharise was frustrated with Brittney for not com-
ing to her. The therapist shifted Sharise’s tone by
acknowledging her love and concern for Brittney
and asking her to share those emotions: “Let your
daughter know how sad you are that she does not
trust you. Let her know how worried you are that
she is all alone.”
This softened the mood in the room and shifted
the family from anger to sadness. At this point,
Brittney and Sharise could focus on interpersonal
ruptures instead of problem behavior. Both
mother and daughter were able to remember the
close relationship they once shared and how dis-
tant they had become. The therapist helped them
acknowledge that they felt this loss of closeness.
With the relational narrative now at the center of
Attachment-Based Family Therapy
the conversation, Sharise agreed to the relational
treatment contract: to make relationship repair the
initial goal of the treatment. Brittney was more
hesitant. She, like many adolescents, had lost
hope that family relationships could improve.
Brittney was protecting herself from further hurt
by no longer wanting attachment security. The
therapist validated this concern but also talked
about the consequence of being so alone in life:
depression and suicide. After the therapist
explored her resistance and validated her con-
cerns, Brittney agreed to come to the next session
and discuss this further with the therapist alone.
Task II: Adolescent Alliance. The therapist
met with Brittney for her first Task II session to
continue building an alliance and to better under-
stand her depression and suicidal ideation. After
this initial session, Brittney participated in two
more Task II sessions where she discussed what
got in the way of going to her mother for help and
support (e.g., relational ruptures). Brittney noted
two ruptures that were different from those origi-
nally identified in Task I. First, rather than being
worried about her mother’s opinion of her or
feeling like a burden, Brittney actually felt
attacked and humiliated by her mother. Specifi-
cally, she said that when she shared things with
her mother, the mother would then follow her
around the house and “yell” at her if she did not
keep talking about these things. If she brought up
feelings about her father, her mother would “lash-
out” and reprimand her for wanting a relationship
with such a “horrible man.”
Brittney also described feeling abandoned by
her mother during the scariest moments in her life.
Brittney had witnessed episodes of domestic vio-
lence that her mother suffered at the hands of
multiple romantic partners. This had never been
discussed before. In sessions, Brittney talked
about the impact that witnessing the violence
had on her as well as the consequences of not
being able to talk with her mother about these
events. These conversations helped Brittney
understand how these relational ruptures impacted
her sense of safety and security in her relationship
with her mother (i.e., her attachment rupture nar-
rative). The therapist spent the fourth session of
Task II helping Brittney see the link between her
5
attachment narrative and her depression and sui-
cidal ideation. Understanding this link motivated
Brittney to talk to her mom about the ruptures.
The therapist then spent time preparing Brittney
for these conversations.
Task III: Caregiver Alliance. In this task,
Sharise was initially very guarded and worried
about being judged or blamed for her daughter’s
problems. In the first session of Task III, the
therapist got to know Sharise better, including
her work responsibilities, social life, supportive
relationships, and current stressors. Sharise was
burdened with balancing childcare and her job.
She described feeling “stressed,” “exhausted,”
and “guilty” on a daily basis. Sharise acknowl-
edged that these stressors impacted her capacity to
be present with her children. The therapist also
helped her realize that when she felt worried about
her daughter (e.g., when Brittney failed to arrive
home on time), this would trigger her own feel-
ings of guilt. Sharise actually attributed her
daughter’s acting out behavior as a result of her
own lack of availability as a mom. When these
feelings of guilt were triggered, Sharise tended to
lash out verbally at her daughter. Despite this
initial work to understand how current stressors
impacted her, Sharise remained highly defensive.
In the next Task III sessions (sessions two and
three), the therapist explored Sharise’s
intergenerational history, specifically helping her
talk about vulnerable moments as a child. At first,
Sharice resisted exploring her own history of
attachment ruptures. The therapist worked slowly
with Sharise to uncover fears and disappointments
resulting from witnessing domestic violence in
her own family of origin. The therapist used infor-
mation gathered in Task II with Brittney to look
for similar attachment themes in mom’s life.
Sharise struggled to emotionally connect to her
own childhood experiences of betrayal and
abandonment.
In the therapy, Sharise would often distance
herself from the emotional intensity of the con-
versation by flippantly saying, “Oh I just had to
get over all this.” Each time Sharise retreated like
this, the therapist would gently invite her back
into uncovering more vulnerable feelings. To
stay in this zone, Sharise’s primary emotions
6 Attachment-Based Family Therapy
related to abandonment and neglect needed to be
identified and validated. Only when Sharise could
allow herself access to these more vulnerable feel-
ings could she begin to have more empathy, rather
than indifference, for her own painful experiences
as a child.
Once she was able to acknowledge this, the
therapist helped her empathize with her daugh-
ter’s experience of witnessing domestic violence
and having no one to turn to for support. Sharise
quickly realized what her daughter needed to
resolve these frightening experiences.
Brittney needed to have someone help her
understand these frightening events and tell her
it was not her fault; just what Sharise wished she
had gotten from her mother.
The therapist spent the fourth session of Task
III helping Sharise identify how themes of aban-
donment permeated her own life and her current
approach to parenting. Sharise acknowledged that
she was “walking with blinders on.” She admitted
that she wanted to deny that the witnessing of
domestic violence had an effect on her daughter.
She also acknowledged that she attacked her
daughter out of guilt. Specifically, when her
daughter unknowingly reminded Sharise of her
own “failings” as a caregiver, she felt accused
and blamed. Sharise now recognized how her
daughter must have felt during their times of con-
flict; Sharise said “I didn’t know how to manage
my own hurt when Brittney needed me.” In this
task, Sharise developed a new narrative about
herself, her childhood, and her parenting – an
approach that had more tolerance for painful feel-
ings. In the fifth and final Task III session, the
therapist offered Sharise the opportunity to
change her relationship with her daughter. Once
Sharise agreed, the therapist prepared her for the
first Task IV conversation.
Task IV: Repairing Attachment. Building on
the preparation in Task II and Task III sessions,
Brittney and Sharise immediately engaged in an
attuned discussion about relational ruptures in
Task IV. In the first session of Task IV, they
discussed how Brittney felt alienated and attacked
by her mother when she tried to talk to her about
upsetting experiences. After some discussion of
this, Brittney shared her feelings of being rejected
by her father and how bad this made her feel about
herself. With the help of the therapist, Sharise
listened to her daughter’s feelings with empathy,
rather than criticism and interrogation. In fact,
Sharise was so moved by Brittney’s sadness that
she physically moved closer and comforted her
daughter as she cried. In this moment, the thera-
pist had the adolescent sharing vulnerable feelings
and the parent providing comfort and protection: a
corrective attachment experience. This conversa-
tion also laid the foundation for the more difficult
discussions about domestic violence.
In the second Task IV session, they talked
about Brittney’s experience of fear and abandon-
ment during the episodes of domestic violence.
With the support of the therapist, Brittney
disclosed feeling abandoned by her mother
because she had never asked Brittney about
these events. After mom validated, rather than
dismissed, Brittney’s feelings, Brittney began to
share her memories of the violence. In this con-
versation, the therapist encouraged Sharice to lis-
ten, be curious, ask questions, and not talk too
much. The therapist also discouraged her from
apologizing too quickly, as this often brings clo-
sure to a conversation that the therapist wanted to
sustain. When the time was right and Brittney had
shared her full story, Sharise gave her daughter an
honest apology for not being there for her during
those difficult times. Sharise also shared a bit
about her own life experiences as a child, but not
so much that the mom would become the center of
attention.
In Task IV sessions, the conversations between
Brittney and Sharise were different from those in
the past. Mom was softer and Brittney was more
willing to share her experiences and emotions
openly. At the end of Task IV, the therapist asked
the family to reflect a bit on how these conversa-
tions had gone. Mom and daughter both acknowl-
edged how different the other one had been: both
more open, more receptive, and more honest.
They both realized how often they bury their
hurt feelings and how much better it was to
share them with each other. Mom and daughter
only needed two Task IV sessions before moving
on to Task V.
Attachment-Based Family Therapy
Task V: Promoting Autonomy. Sharise and
Brittney had four Task V sessions to discuss issues
contributing to Brittney’s depression (e.g., being
bullied, struggling to fit in, school attendance),
plans for the future (e.g., work, college), and
personal development (e.g., sexuality, romantic
relationships, biracial identity). All of these con-
versations allowed Sharise to practice supporting
her daughter on her path toward womanhood. The
therapist encouraged Sharise to serve as a support
for her daughter (i.e., help Brittney express her
emotions and make better decisions). By the end
of Task V, the family felt like trust was coming
back, reducing mom’s worries about her daugh-
ter’s “out of control” behaviors and increasing
Brittney’s tendency to go to mom for support.
Case Review. At the close of the final session,
both mom and daughter felt able to continue hav-
ing conversations together about future difficul-
ties. Brittney began college preparatory courses
with her mom’s support and actively visited local
community colleges to learn more about business
programs. By the end of therapy, Brittney had
begun thinking about the possibility of starting a
hair styling and braiding service. Suicide was no
longer a needed coping strategy, and the family
had a plan in place if suicidal thoughts returned.
Specifically, Brittney felt like she could go to her
mom for care and support. Brittney’s depressive
symptoms and suicidal ideations had dropped to a
nonclinical level. Brittney and Sharise found
ABFT to be successful in helping them regain
their closeness. Although not all cases go this
smoothly, many families successfully progress
through the five tasks in 12 to 16 weeks. ABFT
can accomplish this rapid progress because the
model focuses directly on the issues that lie at
the heart of the matter for families: love, commit-
ment, and trust.
Cross-References
▶ Adolescents in Couple and Family Therapy
▶ Alliance in Family Relationships
▶ Attachment in Couples and Families
▶ Attachment Theory
▶ Contextual Family Therapy
7
▶ Emotionally Focused Couple Therapy
▶ Emotion-Focused Therapy for Couples
▶ Enactment in Structural Family Therapy
▶ Multidimensional Family Therapy
▶ Primary Emotions in Couple and Family
Therapy
▶ Softening in Emotion-Focused Therapy
▶ Structural Family Therapy
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