Attachment-based family therapy versus nondirective supportive therapy for lesbian, gay, bisexual and questioning adolescents with depression, and suicidal ideation: An exploratory study.

INTRODUCTION: Lesbian, gay, bisexual, and questioning (LGBQ) adolescents are particularly at risk for suicidal ideation; however, little clinical research is focused on treating this population. Attachment-based family therapy (ABFT) is among the few empirically supported youth suicide treatments adapted for LGBQ adolescents. The purpose of this exploratory study is to determine the differential treatment effects and rates of change for LGBQ and heterosexual adolescents with depression and suicidal ideation receiving either ABFT or family enhanced nondirective supportive therapy (FE-NST). METHOD: The sample included 129 adolescents (31% LGBQ), ages 12-18 randomized to the two treatment groups. Multilevel modeling was used to examine individual changes in depression and suicidal ideation over the 16-week treatment. RESULTS: Results revealed that LGBQ adolescents in the ABFT condition showed a greater rate of reduction in depressive symptoms over treatment, slope = -0.94, p < 0.001, than did LGBQ adolescents in the NST condition, slope = -0.41, p = 0.12. Heterosexual adolescents showed symptom reduction in both treatment conditions (ABFT slope = -0.47, p < 0.001; NST slope = -0.79, t (113) = -7.48, p < 0.001). Changes in suicidal ideation were found across time, but not across conditions. CONCLUSION: LGBQ adolescents in the ABFT condition had a sharper decrease in depressive symptoms and better outcomes at week 16.

Immersive and reflective recall of a suicidal episode: Implications for assessing and treating suicidal adolescents.

OBJECTIVE: The present study tested the validity and clinical utility of adolescents' reports of two distinct modes of processing during the recall of a suicidal episode in the Suicide Narrative Interview (SNI). Recall Intensity (RI) items were designed to capture a tendency to become immersed in thoughts and feelings during the interview, while Meaning Making (MM) items were designed to assess more distant and reflective processing. METHOD: The construct and predictive validity of pretreatment MM and RI was tested in a 16-week randomized clinical trial (RCT) for depressed and suicidal adolescents (N = 113, Mage = 14.95, 84.1% female, 51.8% Black/African American). Adolescents rated MM and RI immediately following the SNI during a baseline assessment. RESULTS: Baseline MM was associated with protective factors related to reduced suicidality, and RI was associated with several risk factors for suicidal symptoms. Adolescents who reported high MM and low RI reported greater reductions in both suicidal ideation and depressive symptoms during the RCT. CONCLUSIONS: The results support MM and RI as two distinct modes of how adolescents process memories of suicidal episodes and highlight the potential clinical utility of RI and MM in assessing and treating suicidal adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety.

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Family relationships and the interpersonal theory of suicide in a clinically suicidal sample of adolescents.

In a sample of suicidal adolescents (N = 117), we sought to identify how adolescents' attachment to their parents related to a key mechanism of suicide from the Interpersonal Theory of Suicide (IPTS). We tested both attachment-anxiety and attachment-avoidance, to both mother- and father-figures as correlates of the IPTS construct, perceived burdensomeness (PB). In addition, we tested PB as a mediator between these attachment variables and adolescent suicide ideation in a path analysis. Our path analysis indicated both mother- and father-related attachment anxiety were associated with PB and PB was related to suicide ideation. We also found an indirect effect of father-related attachment anxiety on suicide ideation. This study provides empirical support for earlier systemic work that proposes how family relationships may influence an adolescent's suicidal ideation. Finally, we provide practical clinical suggestions for how therapists may implement a systemic framework to address a suicidal adolescent and their family relationships.

Anxiety-related difficulties in goal-directed behavior predict worse treatment outcome among adolescents treated for suicidal ideation and depressive symptoms.

Although treatments for youth at risk for suicide have been successful, they are not similarly effective for everyone. Anxiety may interfere with adolescents' ability to engage with therapy and explain why some adolescents do not respond as well as others to treatment. The current study tested whether an anxiety diagnosis predicted treatment outcome among a sample of adolescents with suicidal ideation and depressive symptoms participating in either attachment-based family therapy or family-enhanced nondirective supportive therapy (N = 129; M age = 14.87, SD = 1.68; 81.9% female). The data set that the current study used had a high representation of Black/African American adolescents (48.8% of sample), which is valuable, as few studies have included adequate representation of this population. A significant indirect effect (.88; 95% confidence interval [.01, 2.64]) showed that across both treatment conditions, participants who met criteria for an anxiety disorder had greater difficulties engaging in goal-directed behavior midtreatment, and these difficulties, in turn, predicted more posttreatment suicidal ideation. The effect of anxiety on treatment outcome via difficulties with goal-directed behavior was nonspecific to the treatment condition. However, attachment-based family therapy was superior to family-enhanced nondirective supportive therapy in improving this aspect of emotion regulation among adolescents who did not have anxiety. In addition, difficulties with goal-directed behavior on treatment outcome were worse for adolescents' who reported greater attachment avoidance to their parents. Future research should test whether targeting goal-directed behavior and attachment avoidance would result in better treatment outcome for adolescents with suicidal ideation and anxiety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploring the relations between interpersonal risk and adolescent suicidality during treatment.

OBJECTIVE: Despite considerable evidence that supports perceived burdensomeness (PB) and thwarted belongingness (TB) as risk factors for suicidal ideation (SI), far less is known about the direction of effects between these constructs in treatments for suicidal adolescents. The present study examined bidirectional relations between PB, TB, and adolescents' suicidal ideation (SI) during a 16-week randomized clinical trial. METHOD: 129 depressed and suicidal adolescents completed PB, TB, and SI measures at three time points: baseline (T1), mid-treatment (T2), and treatment completion (T3). Random-intercept cross-lagged panel models (RI-CLPM) examined within-subject direction of effects between interpersonal variables (PB & TB) and suicidal ideation (SI) in the first and second halves of treatment. RESULTS: Within-subjects, autoregressive paths indicated significant carryover in PB and SI. In the first half of treatment, a significant cross-lagged path indicated that T1 PB predicted change in T2 SI, and in the last half of treatment change in T2 SI predicted change in T3 PB. There were no significant auto-regressive or cross-lagged effects for TB. CONCLUSIONS: In the first half of treatment, baseline PB predicted fewer reductions in SI suggesting that PB initially moderated adolescents' response to treatment. However, in the last half of treatment, initial reductions in SI predicted subsequent reductions in PB suggesting that adolescents' initial response to treatment decreased their perceptions of burdening others. The clinical and treatment implications of these bidirectional findings are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Emotional processing in attachment-based family therapy for suicidal adolescents.

Objective: This study examined proposed sequential pathways through which suicidal adolescents are thought to shift from secondary global distress and rejecting anger to primary adaptive hurt, grief and assertive anger in the context of attachment-based family therapy (ABFT). Method: Participants were 39 suicidal adolescents who had received 16 weeks of ABFT as part of a randomized clinical trial, and who had been assigned to one of three outcome groups (i.e., good responders, slow responders and non-responders). Adolescents' in-session emotions were observationally coded using the Classification of Affective-Meaning States. Results: Across outcome groups, adolescents evidenced shifts from global distress to maladaptive shame, from maladaptive rejecting anger to adaptive assertive anger, and from adaptive assertive anger to adaptive grief/hurt. Adolescents who did not respond to treatment evidenced higher rates of maladaptive global distress. Conclusions: Findings are discussed in the context of ABFT and sequential emotional processing theories.

Testing Basic Assumptions of the Interpersonal Needs Questionnaire-15 in a Sample of Clinically Depressed and Suicidal Youth.

OBJECTIVE: Suicide is a leading cause of death in adolescence. The mechanisms of adolescent suicidality, however, are not fully understood. Although the Interpersonal-Psychological Theory of Suicide, as assessed by the Interpersonal Needs Questionnaire-15 (INQ), may be a promising framework, systematic study of its utility during adolescence is lacking. METHOD: To this end, we utilized factor analyses and hierarchical regression analyses to test the factor structure, correlates, and predictive validity of the INQ in a sample of clinically depressed and suicidal adolescents (N = 120, aged 12-18). The sample was mostly female (81.9%), ethnically diverse (68.2% non-White) and with nearly a third identifying as a sexual minority (31.8%). RESULTS: Contrary to studies including adult samples in which a two-factor solution is identified, results within this sample indicated three factors: perceived burdensomeness, thwarted belongingness, and perceived isolation. Perceived burdensomeness and the interaction between perceived burdensomeness and perceived isolation predicted suicide ideation above and beyond depression, but thwarted belongingness and perceived isolation did not. CONCLUSION: Perceived burdensomeness appears to play a role in adolescent suicidality and may be a point of intervention, yet the notable deviation from previous findings and the relative weakness of two of the factors warrant further study.

Therapist Interventions Associated with Productive Emotional Processing in the Context of Attachment-Based Family Therapy for Depressed and Suicidal Adolescents.

Productive emotional processing is considered a key change mechanism in attachment-based family therapy (ABFT). This study examined the impact of attachment-based family therapy therapist interventions aimed to promote productive emotional processing of primary adaptive emotions in a sample of 30 depressed and suicidal adolescents who had participated in a larger randomized clinical trial. Results of sequential analyses revealed that relational reframes and therapists' focus on primary adaptive emotions were associated with the subsequent initiation of adolescents' productive emotional processing of primary adaptive emotions. In contrast, interpretations, reassurances, and therapists' focus on adolescents' rejecting anger toward their parents were all followed by the discontinuation of adolescents' emotional processing that had already begun. Finally, therapists' general encouragement of affect and focus on adolescents' unmet attachment/identity needs were associated with both the initiation of adolescents' productive emotional processing, and with the discontinuation of such processing once it had already begun. Theoretical and clinical implications are discussed.

El procesamiento emocional productivo (Greenberg, Auszra y Hermann, 2007) se considera un mecanismo de cambio clave en la terapia familiar centrada en apego (ABFT en inglés; Diamond, Diamond, & Levy, 2014). Este estudio examinó el impacto de intervenciones terapéuticas ABFT dirigidas a promover el procesamiento emocional productiva de emociones adaptativas primarias en una muestra de 30 estudiantes deprimidos y suicidas que participaron en un ensayo clínico aleatorio de mayor escala. Los resultados de los análisis secuenciales revelaron que los reencuadres relacionales y el enfoque de los terapistas en las emociones adaptativas primarias se asociaron al inicio subsiguiente del procesamiento emocional productivo de emociones adaptativas primarias por parte de los adolescentes. En cambio, las interpretaciones, afirmaciones y el enfoque de los terapistas en el enojo rechazador de los adolescentes hacia sus padres fueron seguidas por la suspensión del procesamiento emocional que había ya comenzado. Por último, la motivación general por parte de los terapistas del afecto y enfoque en las necesidades insatisfechas de apego/identidad de los adolescentes se asociaron tanto al inicio del procesamiento emocional productivo de los adolescentes como a la suspensión de dicho procesamiento cuando había ya comenzado. Se discuten las implicaciones teóricas y clínicas.

Parent-teen communication predicts treatment benefit for depressed and suicidal adolescents.

OBJECTIVE: Although there are currently several efficacious treatments for depressed and suicidal adolescents, less is known about predictors and moderators of adolescents' treatment response. A growing literature has identified family functioning as a prognostic indicator of adolescents' likelihood of benefiting from treatment. The current study tested both observational and perceived measures of family functioning as indicators of adolescents' response to 2 treatment conditions. METHOD: The sample consisted of 129 depressed and suicidal adolescents (Mage = 14.96, 82.9% female, 56% Black/African American) who were randomized to attachment-based family therapy or family-enhanced nondirective supportive therapy (Diamond et al., 2019). Baseline assessments of family functioning included ratings of parent-adolescent communication coded with the Goal-Corrected Partnership in Adolescence Coding System (Lyons-Ruth, Hennighausen, & Holmes, 2005) and adolescent and parent reports of Family Conflict and Cohesion from the Self-Report of Family Functioning (Bloom, 1985). RESULTS: Adolescents who engaged in more uncooperative communication with their parents during a 10-min conflict discussion showed greater reductions in depressive symptoms in both treatments. Adolescents from traditionally underserved (non-White or lower income) families showed greater reductions in suicidal ideation in both treatments. CONCLUSIONS: Attachment-based family therapy and family-enhanced nondirective supportive therapy were most effective for adolescents from traditionally underserved families and adolescents who engaged in less cooperative communication with their caregivers. Observational ratings of parent-adolescent communication were better prognostic indicators of treatment response than were self-reported indicators of global family functioning. Implications for generalizing these results to other treatments for depressed and suicidal adolescents are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Dr. Diamond Replies.

The Letter to the Editor by Verhees et al. raises interesting questions about how to potentiate the mechanism of change in attachment-focused therapies.1 The basic assumption of attachment theory is that that children who grow up with insensitive or inconsistent parenting or trauma internalize a view of the world as unsafe and view themselves as unworthy of love and protection. These early relational experiences lay down the foundation of one's view of oneself and expectation of others. This schema, combined with temperament and biology, inform and influence future relationships and experiences. But for Bowlby, because the internal working model is shaped by relational experience, it is continually open for revision if the environment were to change.2 As psychotherapists, we aim to facilitate that revision.

Identifying Risk Factors for Disordered Eating among Female Youth in Primary Care.

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14-24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

Predicting Patterns of Treatment Response and Outcome for Adolescents Who Are Suicidal and Depressed.

OBJECTIVE: Although several treatments have been shown to be effective in treatment of youth suicidal thoughts and behaviors (STBs), there is a pressing need to account for the substantial variation in adolescents' response to and outcomes from these treatments. METHOD: Secondary analyses of data from a 16-week randomized trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced NonDirective Supportive Therapy (FE-NST) identified distinct classes of adolescents' treatment response. Established risk factors for STBs, along with treatment condition and sociodemographic variables, were then tested as predictors of class membership. RESULTS: Three patterns of adolescents' treatment response and outcome were identified: a) nonresponders (15.8%), b) good responders (57.5%), and c) partial responders (26.7%). After controlling for initial symptom severity, nonresponders were more likely to have higher levels of nonsuicidal self-injury and pessimism and were more likely to meet diagnostic criteria for major depressive disorder (MDD) than good or partial responders. Partial responders were more likely than good responders to meet criteria for MDD and to have higher perceived burdensomeness. CONCLUSION: Although most adolescents showed significant symptom reductions with both treatments, adolescents with higher pretreatment levels of pessimism, MDD, nonsuicidal self-injury, and perceived burdensomeness were less likely to show an optimal pattern of treatment benefit. The findings point to heterogeneity in treatment response that may require adapting treatments for adolescents with these pretreatment profiles. CLINICAL TRIAL REGISTRATION INFORMATION: Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

Differences in Suicide Risk Severity Among Suicidal Youth With Anxiety Disorders.

Background: Adolescent suicidality is a growing public health concern. Although evidence supports a link between anxiety and suicidality, little is known about risk associated with specific anxiety disorders. Aims: This study examined the prevalence of anxiety disorders in a sample of adolescents with depression and suicidal ideation and the associations between specific anxiety disorders and suicide ideation severity and attempt history. Method: The sample consisted of 115 adolescents (Mage = 14.96 years; 55.8% African American) entering a clinical trial for suicidal ideation and depressive symptoms. Prior to treatment, adolescents completed self-report and interview measures. Results: In all, 48% of the sample met criteria for an anxiety disorder, 22% met criteria for social anxiety disorder (SAD), and 40% met criteria for major depressive disorder (MDD). SAD was uniquely associated with more severe suicidal ideation. Limitations: Findings may not generalize to all suicidal adolescents, and non-measured variables may account for the observed relationships. Conclusion: Future research should examine whether targeting social anxiety would improve treatment response for suicidal adolescents.

A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal.

OBJECTIVE: To evaluate the efficacy of attachment-based family therapy (ABFT) compared with a family-enhanced nondirective supportive therapy (FE-NST) for decreasing adolescents' suicide ideation and depressive symptoms. METHOD: A randomized controlled trial of 129 adolescents who are suicidal ages 12- to 18-years-old (49% were African American) were randomized to ABFT (n = 66) or FE-NST (n = 63) for 16 weeks of treatment. Assessments occurred at baseline and 4, 8, 12, and 16 weeks. Trajectory of change and clinical recovery were calculated for suicidal ideation and depressive symptoms. RESULTS: There was no significant between-group difference in the rate of change in self-reported ideation (Suicidal Ideation Questionnaire-Jr; F1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t127 = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t127 = 10.88, p < .0001; effect size, d = 1.93). Response rates (ie, ≥50% decrease in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST. CONCLUSION: Contrary to expectations, ABFT did not perform better than FE-NST. The 2 treatments produced substantial decreases in suicidal ideation and depressive symptoms that were comparable to or better than those reported in other more intensive, multicomponent treatments. The equivalent outcomes could be attributed to common treatment elements, different active mechanisms, or regression to the mean. Future studies will explore long-term follow up, secondary outcomes, and potential moderators and mediators. CLINICAL TRIAL REGISTRATION INFORMATION: Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

Depressive symptoms and self-harm among youngsters referred to child welfare: The role of trust in caregiver support and communication.

Depressive symptoms and self-harm, i.e. non-suicidal self-injury and suicidal behaviors, are highly prevalent in youngsters involved in Child Welfare System (CWS) services. Little research investigates, however, why these CWS youngsters are at risk. We explored whether trust in caregiver support and communication about experiences with primary caregivers, are associated with CWS youngsters' depressive symptoms and/or self-harm. An anonymous online survey of 271 CWS youngsters (10-21 years of age, 57.2% female) was used to assess trust and communication, and depressive symptoms/self-harm. Results showed significant negative associations between self-reported trust in maternal and paternal support, and depressive symptoms/self-harm. Communication about experiences with one's biological mother mediated the relationship between trust in maternal support and depressive symptoms/self-harm. Furthermore, the presence of an additional trustworthy caregiver buffered the impact of low trust in maternal or paternal support on depressive symptoms/self-harm. Implications for interventions targeting CWS youngsters' depressive symptoms and self-harm are discussed.

Religion, Sexual Orientation, and Suicide Attempts Among a Sample of Suicidal Adolescents.

Despite condemnation of same-sex attraction by certain religious groups, few studies have explored the relationship between religion, same-sex attraction, and suicidality. This study examined the moderating effect of same-sex attraction on the relationship between parent/adolescent religiosity and suicide ideation/attempts in a suicidal adolescent sample (N = 129). Linear and negative binomial regressions tested the effects of a two-way dichotomous (same-sex attraction, yes/no) by continuous (religiosity) interaction on ideation and attempts, respectively. The interaction was not significant for ideation. However, high religiosity was associated with more attempts in youth reporting same-sex attraction but fewer attempts in those reporting opposite-sex attraction only.

Comprehensive Screening for Suicide Risk in Primary Care.

INTRODUCTION: Suicide is a major public health problem and a complex clinical challenge. Assessment and early identification could be enhanced with screening tools that look beyond depression. The purpose of this study was to identify profiles of risk behaviors and social stress associated with suicidal ideation and behavior using the Behavioral Health Screen. METHODS: The study used screening data from 2,513 primary care patients (aged 14-24 years). Data were collected between 2008 and 2012, and were analyzed in 2016. RESULTS: Latent class analysis identified a high and low risk profile. Domains of primary influence included substance use, sexual assault, same-sex behavior, and unsafe sex. The high-risk group was 11 times more likely to have made a suicide attempt, five times more likely to report a history of suicidal ideation and behavior, and three times more likely to report recent suicidal ideation and behavior. CONCLUSIONS: Risk behaviors and social stress contribute to the risk for suicide above and beyond depression and should be assessed during routine primary care visits with adolescents. The Behavioral Health Screen can screen all these domains and thus assist primary care providers in assessing for both psychiatric and social stress factors associated with youth suicide.

Exploring Acceptability and Feasibility of Evidence-Based Practice in Child Welfare Settings: A Pilot Study with Attachment-Based Family Therapy.

The Flemish Child Welfare System (CWS) is in great need of a shared empirically informed clinical strategy for working with depressed adolescents and their families. Many evidence-based practices (EBP) exist, but little is known as to whether they can be successfully imported in the CWS. Therefore, the current study explores the implementation of a particular EBP, Attachment-Based Family Therapy (ABFT), in home-based services of the Flemish CWS in Belgium. Specifically, the study focused on (1) the acceptability of ABFT by counselors and whether negative attitudes about EBP can be changed (n = 73 counselors), and (2) the feasibility of implementing ABFT (n = 43 adolescents, 11-17 years old, 72% female) by exploring initial effectiveness. The results suggest that (1) initial negative attitudes of counselors towards ABFT were significantly more positive after attending training and discussions about ABFT, and that (2) ABFT could be used by counselors to successfully reduce adolescent depressive symptoms. Future research should include a control group to draw stronger causal conclusions. Strengths and limitations of the study's design and implications for further dissemination are discussed.

The Suicide Narrative Interview: adolescents' attachment expectancies and symptom severity in a clinical sample.

Insecure attachment styles have consistently been identified as risk factors for adolescent psychopathology and, more specifically, suicidal ideation. However, much less is known about the mechanisms that account for the relationship between attachment styles and severity of suicidal ideation within clinical samples. In the current study, adolescents' expectancies for caregiver availability and responsiveness were coded from transcripts of the Suicide Narrative Interview in a clinical sample of 129 depressed and suicidal adolescents. Results indicated that negative expectancies for caregiver availability in the Suicide Narrative Interview were associated both with attachment insecurity and with the intensity of adolescents' suicidal ideation. The implications of adolescents' expectancies for caregiver availability as targets for clinical intervention are discussed.