PORTLAND, ORE. – In a randomized trial, attachment-based family therapy helped depressed, suicidal adolescents more than other approaches even if they had been sexually abused, a factor associated with worse outcomes with other therapies.
The goal of attachment-based family therapy (ABFT) is to strengthen family cohesion as a buffer against adolescent suicidal thinking, depression, and risk behaviors. Parents and teenagers work individually with therapists on communication, trust, self-esteem, and other issues, and then work on them together in family sessions.
The process "puts the burden of change on all the family members," not just the adolescent, said Matthew B. Wintersteen, director of research in the division of child and adolescent psychiatry at Thomas Jefferson University, Philadelphia.
In the trial, 35 adolescents aged 12-17 were randomized to 12 weeks of ABFT; 31 others were referred to 12 weeks of family or individual therapy from community providers and stayed in weekly phone contact with the researchers.
All of the adolescents were depressed and had severe, persistent suicidal ideation; 80% (53) were female and three-quarters were African American. Thirty reported histories of sexual abuse and were more likely to have attempted suicide in the past.
The ABFT group averaged about nine sessions over a period of 12 weeks, while the community care group averaged about three. Subjects’ progress was assessed by interviews and psychological scoring before, during, and after treatment.
In the end, "everybody got significantly better; [the] ABFT [group] just did better," Dr. Wintersteen said at the annual conference of the American Association of Suicidology.
For example, 87% (30) in the ABFT group met criteria for clinical recovery from suicidal ideation, while only 52% (16) met those criteria in the community care group. Twelve weeks after the end of treatment, 70% (25) in the ABFT group had maintained the benefits; just 35% (11) in the community care group had done the same. The results were statistically significant.
Depression remission rates also were significantly better in the ABFT group (J. Am. Acad. Child Adolesc. Psychiatry 2010;49:122-31).
Outcomes were similar among those who had been sexually abused. "Adolescents responded better to ABFT than community care, regardless of" an abuse history, Dr. Wintersteen and his colleagues concluded.
The finding is significant because "recent studies suggest that cognitive-behavioral therapy [CBT]," a common approach for depressed adolescents, "is less effective for adolescents with [sexual] trauma histories," they wrote in their abstract.
CBT, a more structured, problem-solving approach, seeks to identify and change inaccurate beliefs. If families are involved, it’s usually so parents can help young people with CBT skills at home, not to work on family dynamics, Dr. Wintersteen explained.
That, however, is the point of ABFT. A child might be quizzed about why he doesn’t turn to his parents when he is depressed. A parent might be asked, "When your daughter becomes suicidal, why doesn’t she come to you for help?" Answers help identify problems.
Even a parent’s own upbringing might be explored to identify issues that diminish his or her ability to parent.
"We work with parents about how to listen to their kids, and acknowledge and validate their feelings, as opposed to trying to solve their problems all of the time. Parents become a secure base so kids have a sense of support," Dr. Wintersteen said.
The study was funded by the Centers for Disease Control and Prevention. Dr. Wintersteen said he had no relevant financial disclosures.