1. Alliance and Parent Attachment-Promoting Behaviors in Attachment-Based Family Therapy for Depressed and Suicidal Adolescents Copenhagen, June 2014
Menachem M Feder, M.A.
Gary M. Diamond, Ph.D.
Department of Psychology, Ben-Gurion University

2. The Role of Alliance in ABFT First…a word about ABFT
ABFT is a brief, manualized, family-based therapy for depressed and suicidal adolescents
Based on structural family therapy, emotion theory and emotion-focused experiential therapies, normative adolescent research and research on attachment in adolescence
Empirically supported

3. The Structure of ABFT 5 tasks of ABFT: Relational Reframe
Alliance building with adolescent
Alliance building with parent
Attachment task
Fostering independence and problem-solving skills

4. Promoting Attachment in ABFT
Focus on changing quality of adolescent-parent relationship:
Adolescents need to feel comfortable coming to parents in times of need/depressed/suicidal for support, guidance, protection
In-session conjoint attachment episodes (enactments)
Adolescent discloses pain
about relationship with parent/what prevents them from approaching parent
Social rejection, school failure, isolation
Parent responds with validation; support

5. Optimal Attachment Process
Adolescent discloses pain; needs (in relationship with parent and/or dealing with failures & challenges in school, peers, romance, mood)
Parent is curious, non-critical, non-defensive
Adolescent deepens disclosure, explores feelings, uncovers primary emotions
Parent responds optimally, validates, provides info, sometimes apologizes
Adolescent schema/perception of parent changes: parent is more benevolent

6. Challenges for Parents During the Attachment Task
Responding in an attachment-promoting manner can be challenging for parents:
Pain, fear, guilt, hurt, anger
Impulse to explain, correct, defend
Fear of losing authority

7. Parental Attachment-Promoting Behaviors
We want parents to respond in a pro-attachment way:
Ask the adolescent questions in a curious and respectful manner
Encourage adolescent to speak about painful/feared topics
Respond non-critically, non-defensively, and in an empathically-attuned manner

8. Importance of Strong Parental Alliance
In order to help parents respond in this pro-attachment way, despite feeling hurt or fearing losing authority, they must:
Feel supported and cared for by therapist – bond
Agree with the goals of the therapy
Agree with the tasks of the therapy
= Theapeutic Alliance (Bordin, 1979)

9. Alliance in Session Alone With Parent Build Bond
Explore parent’s life story – strengths
Identify [present] stressors
Explore parent’s own experiences of being parented
Explore impact of stressors/needs on parenting

10. Alliance in Session Alone with Parent – Set Goal: Promote Attachment
Place relationship at the center of the conversation
E.g., relational reframe intervention
“Does your daughter come to you when she feels like killing herself?”
“Do you wish it was different?”
“Can we work on that as our first goal of treatment?”

11. Agreement on Task: Implementing Pro-attachment Behaviors
Teach emotion-coaching skills (question, empathize, non-defensive)
Identify potential obstacles (family dynamics)
Get agreement to interrupt when things go wrong

12. Questions Addressed in This Study
Does the strength of parent’s alliance predict parents’ attachment-promoting behaviors in subsequent conjoint attachment session?
Is there a particular aspect(s) of the alliance (bond, goal, task) more strongly predictive?
Is the quality of parental attachment-promoting behavior associated with treatment outcome?

13. Methodology Participants
Clients: 19 cases of depressed and/or suicidal (SIQ > 31; BDI-II > 20)adolescents and their parents
M age = 15.5 yrs; 95% female; 73% ethnic minority
Therapists: 6 expert therapists – 4 PhD-level psychologists (including 3 model-developers), 2 CSW, competent in ABFT

14. Measures Alliance: VTAS-R-SF – observational, 5 item, 6-point
Parental Attachment-Promoting Behavior Scale (PAPBS) – observational, 7 item, 5-point
Outcome: BDI-II and SIQ-Jr

15. Results – Preliminary Data Analyses
Inter-rater reliability
ICCs (1,2) for the 5 VTAS-R-SF items ranged from .74 to .90
ICCs for the 7 PAPBS items ranged from .86 to .96
Principal Components Analysis (PCA) for both scales revealed only one factor for each scale – accounting for 80% and 81% of total variance in each scale, respectively

16. Results: Main Analyses
Strength of parent alliance explains 40% of variance in PAPBS scores (R2 = .40, F(1,17) = 11.33, p< .004
PAPBS scores did not predict reductions in levels of depressive symptoms, F(1,17) = .229, ns
PAPBS scores did not predict reductions in suicidal ideation, F(1,17) = .041, ns

17. Summary of Findings
Strength of parent-therapist alliance predicted parent’s subsequent attachment-promoting behaviors
Parent’s attachment-promoting behaviors did not predict treatment outcome
VTAS-R-SF reliably measured only one distinct alliance factor
PAPBS is a reliable instrument for assesssing parent’s attachment-promoting behaviors

18. Discussion Alliance predicts attachment-promoting behavior
Consistent with emerging research on the role of alliance in intermediate therapeutic tasks
Underscores clinical importance of cultivating strong parental alliance in ABFT
Informs ABFT therapists to monitor parental alliance before proceeding to re-attachment
e.g., Elliott, 2010; Friedlander, Heatherington, & Escudero, 2005

19. Discussion
Parent’s attachment-promoting behaviors did not predict degree of reduction in depression or suicidality
Statistical explanation – insufficient variance
Extra-familial events/factors are not sufficiently moderated by parental support (conflict between parents, intense acute life stressors)
Adolescent responded to therapist’s, not parent’s, empathic support

20. Discussion: Limitations
Measured alliance at only one time point
Future studies should include pre-therapy factors as covariates (parent’s object-relations, attachment behaviors)
Small sample size, predominately single-parent mothers – limits generalizability to other familial situations

21. Thank you for listening!