Family processes: Risk, protective and treatment factors for youth at risk for suicide.

Family factors have continually been identified as potential risk and protective factors for youth at risk for suicide. This paper reviews family processes that not only are associated with suicide risk, but also might be malleable enough to target in treatment. We also review family intervention components have been incorporated into most youth suicide treatments. Unfortunately research on if these family processes moderator, mediator or change as a result of treatment is limited. Recommendations for future research are offered.

Demonstrating Attachment-Based Family Therapy for Transgender and Gender Diverse Youth with Suicidal Thoughts and Behavior: A Case Study.

Suicide is a growing public health issue among adolescents. While the majority of transgender and gender diverse (TGD) youth are healthy, many experience suicidal thoughts and behavior (STB). Due to discrimination and stigma, TGD youth attempt suicide at higher rates then heterosexual, cisgender and even cisgender, LGBQ youth. Despite this vulnerability to suicide, few treatments have been developed and tested for this population. One treatment, attachment-based family therapy (ABFT) has been adapted to work with LGBQ youth and may be promising for TGD adolescents at risk for suicide. This article provides an overview of our ABFT modifications for TGD youth with thoughts of suicide. Specifically, we illustrate how treatment outcomes, in a single case study, relate to processes within clinical treatment tasks. The case study demonstrates the application of these ABFT modifications with a self-identified, gender nonconforming adolescent (who had recently attempted suicide) and his caregivers. Treatment evaluation measures were collected over the course of 24 weeks to illustrate the youth's clinical progress. The youth's suicidal symptoms diminished markedly by the end of treatment. Further, the family reported an increased ability for problem solving and more open communication by treatment conclusion.

El suicidio es un problema de salud pública cada vez mayor entre los adolescentes. Si bien la mayoría de los jóvenes transgénero y de géneros diversos (TGD) son saludables, muchos tienen pensamientos y conductas suicidas. Debido a la discriminación y al estigma, los índices de intento de suicidio en los jóvenes TGD son más altos que en los jóvenes heterosexuales, cisgénero e incluso LGBQ cisgénero. A pesar de esta vulnerabilidad al suicidio, se han desarrollado y se han evaluado pocos tratamientos para esta población. Un tratamiento, la terapia familiar basada en el apego (TFBA), se ha adaptado para trabajar con jóvenes LGBQ y puede ser prometedor para adolescentes TGD en riesgo de suicidio. Este artículo ofrece un resumen de nuestras modificaciones a la TFBA para los jóvenes TGD con pensamientos de suicidio. Específicamente, ilustramos cómo los resultados del tratamiento, en un solo caso práctico, se relacionan con los procesos dentro de las tareas del tratamiento clínico. El caso práctico demuestra la aplicación de estas modificaciones de la TFBA con un adolescente que se identificó como de género no conforme (y que recientemente había intentado suicidarse) y sus cuidadores. Se recopilaron las valoraciones de una evaluación del tratamiento durante el transcurso de 24 semanas para ilustrar el avance clínico del joven. Los síntomas de suicidio del joven disminuyeron notablemente al final del tratamiento. Además, la familia informó una mayor capacidad para resolver problemas y una comunicación más abierta al concluir el tratamiento.

Family and Peer Relationships in a Residential Youth Sample: Exploring Unique, Non-Linear, and Interactive Associations with Depressive Symptoms and Suicide Risk.

Close relationships are consequential for youth depressive symptoms and suicide risk, but nuanced research examining intersecting factors is needed to improve identification and intervention. This study examines a clinical, residential sample of 939 adolescents and young adults ages 10 to 23 years old (M = 15.84, SD = 1.53; 97.7% white, 99.5% non-Hispanic, 55% female). The final model found that family conflict, parental criticism, verbal bullying, and interactions with friends were associated with depressive symptoms in the expected directions, and there were significant interactions with family, peer, and demographic variables. However, most associations with suicide risk were indirect. Associations involving family factors, peer factors, depressive symptoms, and suicide are not always straightforward, and should be understood within a microsystemic context.

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.

Attachment-Based Family Therapy: A Review of the Empirical Support.

Attachment-based family therapy (ABFT) is an empirically supported treatment designed to capitalize on the innate, biological desire for meaningful and secure relationships. The therapy is grounded in attachment theory and provides an interpersonal, process-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.

The systemic-family-individual approach: The heritage and continuation of Mara Selvini Palazzoli's work in integrative psychotherapy.

Since the birth of family therapy, the Milan approach has been known as a foundational systemic model. Nevertheless, following the dissolution of the Milan group, Mara Selvini, alongside Matteo Selvini, Stefano Cirillo, and Anna Maria Sorrentino, began a new trajectory of clinical development, insufficiently examined within the American panorama. After her death, in 1999, the Selvini group continued to adapt and refine her systemic approach which is known today as the systemic-family-individual (SFI) approach. In this article, we delve into the constituents that constitute the SFI approach, elucidating how it furnishes therapists with a structured framework to guide clinical decision-making and the application of integrated theoretical concepts. Ultimately, the article exemplifies the SFI approach's practical application via a clinical case study, showcasing its efficacious navigation.

Attachment-Based Family Therapy to Improve Family Functioning in Adolescent Binge-Spectrum Eating Disorders: An Initial Evaluation Via Case Series Design.

Binge-spectrum eating disorders (EDs; bulimia nervosa, binge eating disorder) often develop during adolescence and are associated with serious psychological and physical consequences. Current treatments for adolescents are highly behavioral in nature and while efficacious, many patients do not reach remission indicating that current treatments fail to target a key maintenance factor for EDs. One potential maintenance factor is poor family functioning (FF). In particular, high family conflict (e.g., arguing, critical comments) and low family cohesion (e.g., warmth, support) are known to maintain ED behaviors. Poor FF can (1) cause or exacerbate an adolescent's use of ED behaviors to cope with life stress and/or (2) inhibit parents from being a resource to adolescents during ED treatment. Attachment-Based Family Therapy (ABFT) is specifically designed to improve FF, and thus may be a promising adjunct to behavioral ED intervention strategies. ABFT, however, has not been tested in adolescents with binge-spectrum EDs. Thus, the current study is the first to evaluate a 16-week adapted ABFT treatment for adolescents with EDs (N = 8, Mage = 16.00, 71.43% female, 71.43% White) fusing together behavioral treatment for EDs with ABFT for highest possible impact. Eight families were treated in an open pilot trial to examine treatment feasibility, acceptability, and preliminary efficacy on FF and eating pathology. Overall, findings were promising. ABFT + B treatment was feasible and acceptable and showed preliminary evidence that it could improve FF and ED behaviors. Future research will test this intervention in a larger sample and further examine the role of FF in maintaining ED symptoms.

"Bringing and Removing Self from the Table": Therapists' use and management of eating disorder lived experience in the treatment of clients with eating disorders.

Therapists report significant countertransference reactions when treating clients with eating disorders (EDs). Countertransference may be pronounced among therapists with eating disorder lived experience (EDLE). Minimal research examines how therapists with EDLE negotiate their experiences while treating ED clients. Informed by the person-of-the-therapist philosophy, this study sought to understand how therapists use and manage their EDLE when working with ED clients. Using constructivist grounded theory methodology, semistructured interviews (Mtime = 89 min) were conducted with 22 therapists with EDLE. Results revealed that therapists engaged in two interconnected systems. The Central System helps therapists transform their lived experiences into clinical guidance. The Checks and Balances System allows therapists to find a balance between connecting with the client and allowing for differences in experiences to emerge. Lastly, three personal processes existing outside of these systems were found to impact therapists' use of self. Findings provide novel ways that therapists can use their EDLE.

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.

Career stage differences in mental health symptom burden and help seeking among veterinarians during COVID-19.

OBJECTIVE: To explore veterinarians' mental health symptom burden during COVID-19 and identify differences in symptom burden, social support, help seeking, and incentives and barriers associated with receiving help across career stages. SAMPLE: Online survey responses from 266 veterinarians between June 4 and September 8, 2021. PROCEDURES: Respondents were grouped by career stage (early [< 5 years of experience], middle [5 to 19 years of experience], or late [≥ 20 years of experience]), and results were compared across groups. RESULTS: Of the 262 respondents who reported years of experience, 26 (9.9%) were early career, 130 (49.6%) were midcareer, and 106 (40.4%) were late career. The overall mean anxiety and depression symptom burden score was 3.85 ± 3.47 (0 to 2 = normal; 3 to 5 = mild; 6 to 8 = moderate; and 9 to 12 = severe), with 62 of 220 (28.1%) respondents reporting moderate to severe symptom burden. Most (164/206 [79.6%]) reported not accessing behavioral health providers, and of these, 53.6% (88/164) reported at least mild symptom burden. There were significant differences in both symptom burden and mental health help-seeking intentions across career stages, with early- and midcareer (vs late-career) veterinarians reporting higher symptom burden (P = .002) and midcareer (vs late-career) veterinarians reporting higher help-seeking intentions (P = .006). Barriers and incentives for seeking mental health care were identified. CLINICAL RELEVANCE: Findings revealed differences in symptom burden and intentions to seek mental health care across veterinary career stages. Incentives and barriers identified serve to explain these career stage differences.

Veterinarians show resilience during COVID-19: challenges faced and successful coping strategies.

OBJECTIVE: To identify challenges veterinarians faced during the COVID-19 pandemic, explore how they coped, identify coping strategies associated with greater resilience, and determine incentives and barriers to performing healthy coping behaviors. SAMPLES: 266 surveys completed by veterinarians in the Potomac region. PROCEDURES: A cross-sectional survey was distributed electronically through veterinary medical boards and professional associations between June and September 2021. RESULTS: Most survey responses came from veterinarians working in Maryland (128/266 [48%]) and Virginia (63/266 [24%]) who were predominantly white (186/266 [70%]), female (162/266 [61%]), and working in small-animal clinical practice (185/266 [70%]). The greatest workplace challenges experienced were increased workloads (195/266 [73%]) and reevaluating existing workflows (189/266 [71%]). Separation from loved ones (161/266 [61%]) was the greatest personal challenge. Of the veterinarians who completed the 10-point Connor-Davidson Resilience Scale (n = 219), which measures resilience on a scale from 0 (no resilience) to 40 (greatest resilience), the mean score was 29.6 (SD, 6.9), with a median of 30 (IQR = 10). Intrinsic factors most strongly associated with greater resilience were increasing age (P = .01) and later career stage (P = .002). Job satisfaction, autonomy, good work-life balance, and approach-focused coping strategies were positively associated with resilience. Overwhelmingly, the primary reported barrier to performing healthy coping behaviors was limited time to devote to self-care (177/266 [67%]). CLINICAL RELEVANCE: A combination of individual approach-focused coping strategies and organizational interventions are crucial to support a resilient veterinary workforce.

Implementing Attachment-Based Family Therapy for Depressed and Suicidal Adolescents and Young Adults in LGBTQ+ Services.

Background: Suicide is a serious public health problem for LGBTQ+ adolescents and young adults. Attachment-based family therapy (ABFT) is one of the few suicide treatment models that has been tested with this population. The challenge remains in how to implement ABFT into the ecology of LGBTQ+ service settings. Aims: In this study, we tested the feasibility, acceptability, and preliminary effectiveness of ABFT in LGBTQ+ community settings. Method: Ten participants were enrolled in 16 weeks of ABFT across three LGBTQ+ organizations. Feasibility (treatment completion) and acceptability (Working Alliance Inventory [WAI]; opinions about treatment [OAT]) were measured for youth and caregivers. Depression and suicide outcomes were assessed for nine participants. Results: ABFT was demonstrated to be both feasible and acceptable. All participants completed treatment, and there were no dropouts. Adolescents/young adults and their caregivers reported high WAI and adequate OAT scores throughout treatment. There was a significant decrease in suicidal ideation (ß = -12.16, t(10) = -3.14, p < .01). Decreases in depression, however, were not significant (ß = -1.83, t(9.11) = -0.88, p = .40). Limitations: The small sample limits our ability to estimate treatment effectiveness. A larger effectiveness trial is warranted. Conclusion: ABFT is a promising treatment for LGBTQ+ service settings.

Review of family-based treatments from 2010 to 2019 for suicidal ideation and behavior.

Suicide ideation and behavior are pervasive public health issues. Given that positive interpersonal relationships can be a protective factor against suicide risk, we conducted a systematic review to examine peer-reviewed publications from 2010 to 2019 that included empirical data, tested an intervention with at least some family component, and included a suicide-related outcome measure. We reviewed and synthesized findings from 22 articles covering 7 intervention categories with 12 interventions to examine the treatment components and the quality of evidence to support them. Using Southam-Gerow and Prinstein's (Child Adolesc Psychol 43:16, 2014) guidelines, we identified two well-established intervention categories that met the highest standards for interventions and three probably efficacious intervention categories. All interventions found focused solely on suicide risk in adolescent populations. More studies are needed for adult populations and to explore the role of family moderators and mediators to test whether suicide outcomes are reduced by improvement in the family environment.

Attachment-based family therapy in the age of telehealth and COVID-19.

The COVID-19 pandemic has transformed so many aspects of our lives. For psychotherapists, telehealth is likely a permanent part of the future mental health landscape. For family therapists using a manualized treatment, this brings unique challenges and creative opportunities. In this article, we describe the adaptation of attachment-based family therapy (ABFT) in the context of telehealth and COVID-19. ABFT is an empirically supported treatment model designed for adolescents and young adults struggling with depression, anxiety, trauma, and suicide. ABFT is a semi-structured, process-oriented, and trauma-informed family therapy model which presents its own unique challenges and benefits in telehealth environments. We present our adaptations based on years of telehealth clinical experience and address how this model supports the impact of COVID-19 on families.

The transition to teletherapy in marriage and family therapy training settings during COVID-19: What do the data tell us?

In the wake of the COVID-19 pandemic, little is known about how university training programs transitioned to teletherapy. This study describes the transition of two university marriage and family therapy (i.e., master's and doctoral) training clinics to teletherapy and presents preliminary analyses of the types of clients and cases that converted to teletherapy. A series of chi-square analyses, a t-test, a logistic regression model, and a multiple linear regression model were employed. Four key findings emerged: (1) most cases converted to teletherapy; (2) Hispanic ethnicity was the only demographic characteristic to significantly predict conversion to teletherapy; (3) individual cases were significantly more likely to convert to teletherapy than relational cases; and (4) the number of prior in-person sessions attended significantly predicted conversion to teletherapy. Teletherapy conversion implications are discussed across four systemic levels: client, student trainee, supervision, and larger systems.

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.

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.

Differences in Mental Health Symptoms Across Lesbian, Gay, Bisexual, and Questioning Youth in Primary Care Settings.

PURPOSE: Lesbian, gay, bisexual, and questioning (LGBQ) youth exhibit significantly higher rates of mental health problems, including anxiety, depression, suicidal ideation, and nonsuicidal self-injury than their heterosexual peers. Past studies tend to group LGBQ youth together; however, more recent studies suggest subtle differences in risk between sexual minority groups. This study examined differences in mental health symptoms across male and female youth who are attracted to the same sex (gay and lesbian), opposite sex (heterosexual), both sexes (bisexual), or are unsure of whom they were attracted to (questioning) in a sample of 2,513 youth (ages 14-24 years). METHODS: Data were collected using the Behavioral Health Screen-a Web-based screening tool that assesses psychiatric symptoms and risk behaviors-during routine well visits. RESULTS: Bisexual and questioning females endorsed significantly higher scores on the depression, anxiety, and traumatic distress subscales than did heterosexual females. Lesbians, bisexual females, and questioning females all exhibited significantly higher lifetime suicide scores than heterosexual females. Interestingly, bisexual females exhibited the highest current suicide scores. Gay and bisexual males endorsed significantly higher scores on the depression and traumatic distress subscales than did heterosexual males. Gay males also exhibited higher scores on the anxiety subscale than heterosexual males, with bisexual males exhibiting a nonsignificant trend toward higher scores as well. CONCLUSIONS: Findings highlight varying level of risk across subgroups of LGBQ youth and suggest the importance of considering LGBQ groups separately in the context of a behavioral health assessment, especially for females.

The relationship between disordered eating and sexuality amongst adolescents and young adults.

Research shows that gay and bisexual males are at increased risk for disordered eating symptoms (DES); however, studies examining DES amongst lesbians and bisexual women have produced mixed findings. Furthermore, few studies have included questioning or "unsure" individuals. This study examined DES symptoms in adolescents and young adults across self-reported sexual attraction and behavior. Participants were recruited from ten primary care sites in Pennsylvania and administered the Behavioral Health Screen (BHS) - a web-based screening tool that assesses psychiatric symptoms and risk behaviors - during a routine visit. As expected, males who were attracted to other males exhibited significantly higher disordered eating scores than those only attracted to members of the opposite sex. Males who engaged in sexual activities with other males also exhibited significantly higher scores than those who only engaged in sexual activities with females. Amongst females, there were no significant differences in DES scores between females who were only attracted to females and those only attracted to males. Those who reported being attracted to both sexes, however, had significantly higher scores, on average, than those only attracted to one sex. More surprisingly, females who were unsure of who they were attracted to reported the highest DES scores of all. These findings are contrary to previous assumptions that same-sex attraction plays a protective role against eating pathology in females. Females who are unsure or attracted to both sexes may actually be at increased risk for developing DES.