Attachment-based family therapy

1. Introduction

Version followed: the five-task ABFT model for depressed and suicidal adolescents of Guy S. Diamond, Gary M. Diamond and Suzanne A. Levy (manual: Diamond, Diamond & Levy, 2014, Attachment-Based Family Therapy for Depressed Adolescents, APA), as summarised in Diamond, Russon & Levy (2016) and in current ABFT Training Program materials (Drexel Center for Family Intervention Science, 2023 presentations; CEBC and Title IV-E Clearinghouse programme profiles). The manual itself is not drawn on; its chapter structure is from a library record. Variants noted where relevant: ABFT for suicidal LGB adolescents, and ABFT-SGM for sexual and gender minority young adults and their non-accepting parents (Diamond & Boruchovitz-Zamir, 2023). [source: CEBC; ACF Clearinghouse; Diamond et al. 2016; manual TOC record; APA ABFT-SGM page]

ABFT is a manualised, brief, trauma-informed, emotion-focused family therapy for adolescents and young adults (roughly 12–25; trainers use it from about 8 to 25+) with depression, suicidal ideation or behaviour, anxiety or family conflict, delivered to the young person plus at least one caregiver. It rests on attachment theory, with clinical roots in structural family therapy (enactment), multidimensional family therapy, emotion-focused therapy and contextual therapy (trust). [source: CEBC; Diamond et al. 2016; E2 training slides]

Theory of change: insensitive caregiving, traumatic events, family conflict and parental psychopathology create attachment ruptures; the young person stops turning to caregivers when distressed, which feeds depression and suicidality. Trust is treated as the foundation: problem-solving and behaviour management are expected to fail until it is rebuilt. Change happens through a corrective attachment experience in conjoint sessions: the adolescent voices vulnerable feelings and grievances in a regulated way, the parent stays available and attuned, and the adolescent's internal working model of the parent (and of self as worth protecting) is revised, aiming at "earned security". A secure base then supports age-appropriate autonomy. [source: Diamond et al. 2016; E2 training slides; ABFT/CAMS 2023 deck]

2. Framework

The model is organised as five sequential treatment tasks rather than fixed sessions; the authors describe it as a "clear road map" that is structured but flexible. [source: Diamond et al. 2016; CEBC]

Format. Weekly sessions of 60–90 minutes, typically 12–16 weeks (can extend to 6–12 months); twice weekly may be needed in Tasks 2–3 (and, in suicidal cases, early on). Therapist meets the family together and the youth and caregivers separately. No homework. Settings: outpatient, home-based, inpatient, residential, day treatment, partial hospitalisation, schools, online. [source: CEBC; ACF Clearinghouse; ABFT/CAMS 2023 deck]

Session counts differ by source (version followed: CEBC/ABFT Training Program figures; others in brackets). [uncertain]

Task	Who attends	Typical sessions	Goal	Move on when
Safety planning (front-loaded, suicidal cases)	Family + youth	Begins at intake, continues	Means restriction, monitoring plan, family-involved safety plan, managing parental reactivity	Plan in place; reviewed throughout
1. Relational reframe	Whole family together	1	Shift focus from the youth as the problem to the relationship as the route to change; contract to work on repairing trust first	Family agrees that improving relationships is the first goal of therapy
2. Adolescent alliance	Youth alone	2–4	Bond; build a coherent narrative of depression/suicidality and of attachment ruptures; prepare youth to raise them with parents	Youth is willing and prepared to express concerns in a regulated, mature way
3. Parent (caregiver) alliance	Caregiver(s) alone	2–4 [ACF: 2–3]	Bond; explore current stressors, couple conflict, intergenerational attachment history; activate caregiving; teach emotion coaching	Caregiver is receptive and ready to listen without defending
4. Attachment task (repairing attachment)	Youth + caregiver(s) together	1–4 [ACF: 1–3; sometimes more]	Youth discloses ruptures; caregiver responds with empathy and acknowledgment; therapist coaches; corrective experience	Several conversations have built confidence in the relationship; parent has responded with warmth and acknowledgment
5. Autonomy-promoting task	Mostly joint; siblings and other supportive adults may join	4–20 [2016 review: 1–10; ACF: 8–9]	Practise new pattern on present-day issues (school, peers, work, identity); caregiver as secure base; youth accountability	Symptoms improved; family can handle new difficult conversations; termination

[source: CEBC; ACF Clearinghouse; Diamond et al. 2016; E2 training slides; ABFT/CAMS 2023 deck]

Notes on versions: one 2023 Training Program deck labels the later phase as building the family's suicide safety net (sharing the suicide narrative with caregivers, daily caregiver check-ins) while elsewhere naming Task V as promoting autonomy; this guide treats the safety-net work as part of safety planning and Task 5. [uncertain] [source: ABFT/CAMS 2023 deck] The 2014 manual's chapter titles are Task I Relational reframe, Task II Adolescent alliance, Task III Parent alliance, Task IV Repairing attachment, Task V Promoting autonomy. [source: manual TOC record] ABFT-SGM (young adults) renames the phases: establishing relationship-building as the shared goal, alliance with the young adult, alliance with parents, the attachment task, consolidating gains and collaborative planning. [source: APA ABFT-SGM page]

Outcome monitoring. Brief depression and suicidal-ideation measure before each session, or at intake and weeks 4, 8, 12, 16. [source: CEBC]

Training, certification and fidelity (needed to describe yourself as ABFT-trained or certified). Minimum: master's in a mental health field (unlicensed therapists supervised); basic family therapy experience recommended. Level I: 3-day introductory workshop (24 h), after which you may say "ABFT Trained (not certified)" and begin using the model. Level II: 22 sessions of 60-minute video case consultation with a certified consultant plus a 3-day advanced workshop (therapist issues, emotion-deepening skills, role-play), presenting at least four cases and two video excerpts, and passing the ABFT exam (80%). Level III (Certified Therapist): at least 10 recorded sessions rated for adherence by certified supervisors, each with a case write-up and self-ratings. Supervisor certification requires roughly 19 further hours. Fidelity is rated with the 29-item Therapist Behavior Rating Scale-3 (TBRS-3) and five task-specific adherence checklists (not reproduced). [source: CEBC; ACF Clearinghouse; ABFT/CAMS 2023 deck]

3. Guiding principles

Relationships are the solution, not the cause. Frame the family as essential to recovery; never blame parents. Practical meaning: talk about distance and lost trust, not fault. [source: ABFT/CAMS 2023 deck; Diamond et al. 2016]
Trust before behaviour management. Do not open with problem-solving, rules or behaviour plans; repair comes first. Practical meaning: when the family pulls to fix school or curfew, redirect to the relationship until Task 4 is done. [source: Diamond et al. 2016; ABFT/CAMS 2023 deck]
Shared responsibility. Change is everyone's job, so the youth feels less pathologised. Practical meaning: give each member a part to play in repair. [source: E2 training slides; ABFT/CAMS 2023 deck]
Principle-based, goal-driven, flexible; intentionality. Each session has a task goal; the order is a road map, not a script. Practical meaning: know which task you are on and what marks its completion. [source: E2 training slides; Diamond et al. 2016]
Person-of-the-therapist. The therapist's own reactions and attachment history matter and are worked on in training and supervision. Practical meaning: notice whom you side with and where you avoid emotion. [source: E2 training slides; ACF Clearinghouse (advanced workshop on therapist issues)]
Directive but supportive, authoritative stance. The therapist models warm, communicative but firm caregiving. Practical meaning: lead the session firmly while staying warm with every member. [source: CEBC]
Emotion as the change ingredient. Elicit vulnerable, primary emotions to loosen rigid beliefs about the problem and the adolescent; productive processing moves from global distress or secondary anger through primary maladaptive emotion (fear, shame) to primary adaptive emotion (adaptive anger, sadness, compassion), and in ABFT it ends in communicating needs directly to the parent. Practical meaning: slow down and deepen when vulnerable feelings appear; aim the emotion at the relationship. [source: Diamond et al. 2016; Tsvieli et al. 2020 abstract]
Uncover relational traumas and discuss them in a regulated way. Abuse, neglect, abandonment, divorce, parental depression and loss are named and talked through, not avoided. Practical meaning: ask directly what broke trust. [source: Diamond et al. 2016]
Enactment over talking about. Learning is consolidated by family members talking to each other in session. Practical meaning: turn the conversation toward each other rather than routing it through you. [source: Diamond et al. 2016]
Common factors in every task. Empathy, support, admiration and acceptance throughout. Practical meaning: find and voice what you respect in each person. [source: Diamond et al. 2016]
Early side-taking with the adolescent, then rebalancing. The therapist leans toward the adolescent's experience early; parents may later need more balance. Practical meaning: protect the parent alliance while giving the youth voice. [source: Diamond et al. 2016]
Safety first in suicidal cases, as a family task. Safety planning is itself a family intervention. Practical meaning: involve caregivers in means restriction and monitoring from session one. [source: ABFT/CAMS 2023 deck]
Coordinate resources. Therapists or case coordinators liaise with schools and other clinicians. [source: CEBC]
Autonomy within connection. The end goal is a goal-corrected partnership in which the caregiver is a secure base and the youth exercises developmentally appropriate independence. Practical meaning: in Task 5, push the youth toward responsibility and parents toward balancing support with encouragement. [source: Diamond et al. 2016; E2 training slides]

4. Intervention inventory

Ordered as delivered. Named interventions come from the sources; the step-by-step breakdowns are the sources' content put into operational order, and any step not stated in a source is tagged [synthesis]. All example language is illustrative unless quoted and cited. The manual's own micro-skills (exact emotion-deepening moves, task checklists) are not drawn on. [uncertain]

4.0 Family safety planning (suicidal youth; starts at intake)

Purpose / when: Front-loaded for any youth with suicidal ideation or behaviour; the plan is itself treated as a family intervention. [source: ABFT/CAMS 2023 deck]
Steps: (1) Do a standard suicide risk assessment with the youth alone and with caregivers [synthesis: standard practice]. (2) Help parents restrict access to means in the home (secure or remove medications, firearms and other lethal means; no method detail). (3) Help parents decide when, how and for how long to monitor the adolescent. (4) Give psychoeducation on handling suicide concerns. (5) Help parents manage their own reactivity (panic, anger, minimising). (6) Build the adolescent's safety plan with parents involved in making and carrying it out. (7) Set up support: therapist contact, a 24-hour crisis line, and twice-weekly sessions where risk is high. The deck mentions "swaddling" for more severe cases but does not describe it. [uncertain] [source: ABFT/CAMS 2023 deck] (8) Re-check ideation each session with a brief measure. [source: CEBC]
Example language (illustrative): To parents: "Your job this week isn't to fix why she feels this way. It's to keep the house safe and check in with her without interrogating her." To the youth: "Who in your family would you let know if things got that bad again?"
Watch for: Parents who swing between over-monitoring and dismissal; a youth who agrees to a plan they will not use. Working: caregivers can describe the plan and their role; the youth names a caregiver as someone they would tell. [synthesis]

4.1 Relational reframe (Task 1)

Purpose / when: First conjoint session (usually one). Shifts the family from "the youth is the problem" to "the relationship is the way forward" and wins agreement that repairing trust is the first goal. Relational reframes also tend to precede the start of productive emotional processing. [source: CEBC; Diamond et al. 2016; Tsvieli et al. 2020 abstract]
Steps: (1) Join briefly with each member and hear the presenting problem. [synthesis] (2) Ask each person how the depression, suicidality or trauma has created distance in the family. (3) Ask the youth why, when they feel this bad, they don't turn to their parents; ask what it is like to deal with it all alone. (4) Highlight ruptures and their consequences: what damaged trust. (5) Amplify the youth's wish for closeness and the parents' wish to care and protect. (6) Frame change as every family member's responsibility. (7) Propose a treatment contract: before tackling behaviour, the family works on rebuilding trust, starting with separate meetings with the youth and with parents. [source: Diamond et al. 2016; E2 training slides; ABFT/CAMS 2023 deck]
Example language: Core trainer questions: "why don't you go to your mom or dad for support?" and "What's the impact of dealing with issues all alone?" [source: E2 training slides]. Illustrative contract: "It sounds like everyone misses being close. Would you be willing to make getting that trust back our first job, before we work on school and rules?"
Watch for: Parents pulling back to symptom or behaviour talk; the youth shrugging off the question. Working: someone softens, a vulnerable feeling is voiced (sadness, missing each other), and the family accepts relationship repair as the first goal. [source: Diamond et al. 2016 (outcome); watch signs are synthesis]

4.2 Joining with the adolescent (Task 2)

Purpose / when: Opening the 2–4 individual youth sessions; builds the bond needed for later disclosure. [source: Diamond et al. 2016; ABFT/CAMS 2023 deck]
Steps: (1) Meet alone. (2) Learn the adolescent's strengths, interests and competencies. (3) Convey admiration and acceptance. (4) Clarify that you are not there to pass on everything to parents, within safety limits. [step 4 synthesis] [source: Diamond et al. 2016]
Example language (illustrative): "Before we talk about the hard stuff, tell me about what you're good at, what you actually like doing."
Watch for: Monosyllabic, guarded youth: stay with interests longer. Working: the youth starts volunteering material. [synthesis]

4.3 Exploring the depression and suicide narrative (Task 2)

Purpose / when: Builds a coherent story of the youth's distress and suicidality. A 2023 Training Program deck sets out four sub-steps. [source: ABFT/CAMS 2023 deck]
Steps: (1) Ask for telling details of the worst events: triggers, and move toward the deepest dread. (2) Sort diffuse distress: build an emotional vocabulary and identify the youth's reasons for suicide. (3) Explore thwarted belongingness and the sense of being a burden. (4) Link the despair to family conflict: identify attachment ruptures and disappointments. [source: ABFT/CAMS 2023 deck]
Example language (illustrative): "Take me to the worst night. What happened just before?" "When you say 'bad', is it more lonely, more scared, more ashamed?" "Do you ever feel your family would be better off without you?"
Watch for: Rising acute risk during exploration: return to the safety plan. Working: the youth moves from vague 'everything sucks' to specific feelings tied to specific relational events. [synthesis]

4.4 Building the attachment rupture narrative (Task 2)

Purpose / when: Identifies what broke trust and how it blocks turning to parents; prepares the content of Task 4. [source: Diamond et al. 2016; E2 training slides]
Steps: (1) Explore the three rupture types: traumatic events, negative family interactions, parental psychopathology. (2) Track the themes: a coherent attachment narrative, breaches of parental trust, the primary emotions attached to them, their impact, and their link to depression and suicidality. (3) Help the youth articulate injustices and disappointments not fully expressed before, without blaming parents. (4) Note protective reasons for silence (for example not wanting to burden a struggling parent). [source: E2 training slides; Diamond et al. 2016]
Example language: Trainer examples of youth statements this work elicits include a teen saying a parent "didn't protect me" and not wanting "to burden my mom". [source: E2 training slides] Illustrative therapist: "So it's not that you don't care what she thinks. It's that you stopped believing she could handle it."
Watch for: Diffuse rejecting anger toward parents; per process research, focusing on that anger, interpreting or reassuring tends to end productive processing, while focusing on primary adaptive emotion (hurt, longing, adaptive anger at an injustice) tends to start it. [source: Tsvieli et al. 2020 abstract] Working: a coherent, emotionally connected account of one or two core ruptures.

4.5 Gaining agreement to talk with parents; entitlement to voice (Task 2)

Purpose / when: End of Task 2; the youth must be willing and ready to raise ruptures in Task 4. [source: ABFT/CAMS 2023 deck; Diamond et al. 2016]
Steps: (1) Increase the youth's sense of entitlement to have a voice and be heard. (2) Make the case for having the conversation (the 2023 deck says to "convince" the adolescent). (3) Teach interpersonal problem solving and emotion regulation so they can express concerns in a more mature, regulated way. (4) Choose which rupture to start with and rehearse how to say it. (5) Agree what the therapist will do if parents react badly. [steps 4–5 synthesis] [source: ABFT/CAMS 2023 deck; Diamond et al. 2016]
Example language (illustrative): "You deserve to have your parents know this. I'll be there, and I'll have met with them first so they're ready to listen."
Watch for: Agreement out of compliance; fear of retaliation (screen for abuse before any conjoint disclosure). [synthesis] Working: the youth can state the concern calmly in rehearsal.

4.6 Joining with caregivers through current stressors (Task 3)

Purpose / when: Opens the 2–4 caregiver sessions; parents often need winning over to a family approach. [source: Diamond et al. 2016]
Steps: (1) Meet with caregiver(s) alone; time alone with parents is central. (2) Ask about current stressors: their relationships, couple conflict, work, mental health. (3) Assess parental teamwork. (4) Empathise with how much they are carrying and show how stressors can affect parenting. [source: Diamond et al. 2016; CEBC; E2 training slides]
Example language: Trainer example: "It must be hard raising an adolescent, let alone a depressed one". [source: E2 training slides]
Watch for: Defensiveness about blame; caregiver depression needing its own referral. [synthesis] Working: the parent talks about themselves, not only the child.

4.7 Exploring the intergenerational attachment legacy (Task 3)

Purpose / when: After joining; activates caregiving instincts and empathy by connecting the parent's own childhood to present parenting. [source: Diamond et al. 2016; ABFT/CAMS 2023 deck]
Steps: (1) Ask how the parent was cared for, comforted and protected growing up, and what ruptures they lived through. (2) Elicit the primary emotions tied to those memories. (3) Link: what they needed then and did not get, and what their child may need now. (4) Use this to build reflective functioning, the capacity to think about the child's mind and feelings. [source: Diamond et al. 2016; ABFT/CAMS 2023 deck; E2 training slides]
Example language: Trainer example: "Nobody was there for you when you were growing up" (followed by linking it to being there for the child now). [source: E2 training slides]
Watch for: Parent overwhelmed by own trauma: contain and pace, and consider separate referral. [synthesis] Working: softening, tearfulness, a statement like "I don't want her to feel what I felt". [illustrative]

4.8 Teaching emotion coaching and preparing for Task 4 (Task 3)

Purpose / when: Once the parent is emotionally receptive; builds the skills to hear the youth's grievances. [source: CEBC; E2 training slides]
Steps: (1) Teach the three emotion-coaching skills: listen, be curious, don't defend. (2) Explain that the goal of Task 4 is for the parent to understand, not to agree, correct or solve. (3) Preview the likely topic (with the youth's permission) and the parent's likely urge to defend or problem-solve. (4) Role-play the parent's response. (5) Agree a signal for when the therapist will step in. [steps 2–5 operationalised; 3–5 synthesis] [source: E2 training slides; CEBC]
Example language (illustrative): "When he tells you what hurt, your only job is to get curious. 'Tell me more' is enough. No explaining yet."
Watch for: Parent agreeing in principle but rehearsing counter-arguments. Working: in role-play the parent can stay with a hard statement without justifying.

4.9 The attachment task: repairing attachment (Task 4)

Purpose / when: The core change event, after both alliances are in place; 1–4 conjoint sessions, sometimes more, possibly twice weekly. Produces the corrective attachment experience and revises the youth's expectations of parental availability. [source: CEBC; Diamond et al. 2016]
Steps (three phases from task-analysis research; coaching from training materials): (1) Set up: remind everyone of the agreed goal and turn the youth and parent(s) to face each other [setup synthesis]. (2) Adolescent disclosure: the youth raises a core rupture in their own words, in a regulated way. (3) Parent response: the parent responds with empathy and acknowledgment rather than defending, minimising or jumping to solutions; the therapist coaches as needed (blocking defence, prompting curiosity, slowing down, encouraging the youth to keep going). (4) Parent disclosure: the parent shares their own experience; in successful sessions this includes an apology described as "both warm and independent" (affiliative but not enmeshed or self-focused). (5) Mutual conversation: the pair move into a more reciprocal exchange. (6) Repeat over further sessions with other ruptures until confidence in the relationship is established. [source: Stern, King & Diamond 2023 abstract; E2 training slides; ABFT/CAMS 2023 deck; Diamond et al. 2016]
Example language (illustrative): To the youth: "Tell your dad, not me, what it was like when he stopped coming to see you." To the parent after a defensive start: "Hold the explanation for now. What do you hear him saying he felt?" To the parent near the end: "Is there anything you want him to know about what was going on for you then?"
Watch for: Successful sessions showed high parental affiliation and autonomy both when affirming the youth's account and when disclosing; unsuccessful ones showed parental enmeshment, hostile belittling, blaming and distancing. [source: Stern, King & Diamond 2023 abstract] Many parents are relieved the youth is talking rather than acting out or self-harming, even when they disagree with the account. [source: Diamond et al. 2016] Working: the youth says more, softens and stays; the parent acknowledges without a 'but'.

4.10 Autonomy promotion (Task 5)

Purpose / when: After repair; mostly joint sessions (siblings and other supportive adults often join) to practise the new pattern on present-day issues and build a goal-corrected partnership with the caregiver as secure base. [source: CEBC; Diamond et al. 2016; E2 training slides]
Steps: (1) Shift focus to the youth's autonomy and competence: school, hobbies, work, emerging maturity at home. (2) Address other contributors to depression and suicide (for example bullying, divorce, peer conflict). (3) Negotiate solutions to everyday challenges that build autonomy while keeping connection. (4) Push the youth toward developmentally appropriate responsibility and accountability; challenge parents to balance support with encouragement. (5) Address identity development (race, gender, sexual identity, religion) as relevant. (6) Prepare the family for future difficult conversations; plan termination. (7) Add any other needed treatment here (for example trauma, eating-disorder or substance work). [source: Diamond et al. 2016; CEBC; ACF Clearinghouse; E2 training slides]
Example language (illustrative): "Now that you two can talk, let's use it. What's one decision about school she wants to make herself, and how will you back her?"
Watch for: Slide back into control or conflict under everyday stress: return briefly to Task 4 skills. Working: the family resolves a live issue in session with less therapist input. [synthesis]

4.11 Building the family's suicide safety net (later phase)

Purpose / when: In suicidal cases, once trust is improved. [source: ABFT/CAMS 2023 deck]
Steps: (1) With the youth's agreement, share the youth's suicide narrative with caregivers. (2) Caregivers take part in suicide monitoring. (3) Caregivers check in daily on the youth's level of suicidal distress. [source: ABFT/CAMS 2023 deck]
Example language (illustrative): "Could you two agree on a two-minute check-in each evening, a number from one to ten, and what happens if it's above a six?"
Watch for: Check-ins turning into surveillance or conflict. Working: the youth reports distress early to a caregiver. [synthesis]

4.12 Emotion deepening and focusing on primary adaptive emotion (all tasks)

Purpose / when: Whenever vulnerable feeling emerges, in individual and conjoint sessions; taught as emotion-deepening skills in the Level II workshop. [source: ACF Clearinghouse; Diamond et al. 2016]
Steps: (1) Notice secondary emotion (global distress, irritable or rejecting anger). (2) Slow down and invite the underlying fear, shame, hurt or longing. (3) Stay with primary adaptive emotion (adaptive anger at an injustice, sadness, compassion) and with unmet attachment or identity needs. (4) Avoid interpretations, quick reassurance and focusing on rejecting anger, which tended to end processing. (5) Direct the emotion toward the relationship: what the person needs from the other. [source: Tsvieli et al. 2020 abstract; Diamond et al. 2016; specific micro-moves synthesis]
Example language (illustrative): "Under the 'whatever', what's there? ... Sad. Stay with that a second. What do you need your mom to understand about that sad?"
Watch for: Emotional flooding; therapist rushing to soothe. Working: the speaker names a specific feeling and need, and voice and pace change.

4.13 Enactment (all tasks, mainly 1, 4, 5)

Purpose / when: Consolidates learning by having family members talk to each other in session, drawn from structural family therapy. [source: Diamond et al. 2016]
Steps: (1) Redirect talk about someone into talk with them. (2) Coach from the side, then step back. (3) Process afterwards what was different. [steps synthesis]
Example language (illustrative): "Can you turn your chair and tell her that directly?"
Watch for: Escalation: interrupt and coach. Working: the pair sustain the exchange.

4.14 Resource coordination and outcome monitoring (throughout)

Purpose / steps: Contact schools and other clinicians; coordinate services; give a brief depression and suicidal-ideation measure each session or at weeks 0, 4, 8, 12, 16, and use rising scores to revisit safety. [source: CEBC]

4.15 Population adaptations

Suicidal LGB adolescents: more individual time with parents to process disappointment, fear and grief about the youth's sexual identity; work on acceptance; raise parents' awareness of subtle invalidating responses. Published as a case study with transcripts (Levy, Russon & Diamond, 2016; full text not drawn on). [source: Diamond et al. 2016; Levy, Russon & Diamond 2016 abstract]
ABFT-SGM (sexual and gender minority young adults with non-accepting parents): aims to reduce parental rejection and build acceptance; phases renamed as in Section 2; manual content not drawn on. [uncertain] [source: APA ABFT-SGM page]
Inpatient aftercare after a suicide attempt: 16 weeks of ABFT, same-day response to referrals, collaboration with hospital staff. [source: Diamond et al. 2016]
Anxiety (combined CBT-ABFT), young adults with unresolved anger toward a parent (real parent conversations over about 10 weeks), trauma, eating disorders (adjunct to family-based treatment for anorexia), substance use: reported extensions; added treatments sit mainly in Task 5. Protocol details not drawn on. [uncertain] [source: Diamond et al. 2016]

5. Handling problems

Source-based items are cited; everything else is marked [synthesis].

Parents reluctant to engage in a family approach. Sources note parents often need winning over. Respond by joining through their stressors (4.6), framing them as essential to recovery rather than the cause, and making the case that trust underpins everything else. [source: Diamond et al. 2016; ABFT/CAMS 2023 deck] If one parent refuses, start with the willing caregiver and invite the other to one Task 3 session about their own stress, not the child. [synthesis]
Parents sidelined by the service. In one implementation a therapist routinely left parents in the waiting room; this defeats the model, since time alone with parents and conjoint work are central. Book parent sessions explicitly. [source: Diamond et al. 2016]
Parents feel the therapist has sided with the youth. Expected after early alignment with the adolescent; rebalance in Task 3 by giving parents your full empathy for their own history and burden. [source: Diamond et al. 2016; response partly synthesis]
Family keeps pulling to behaviour, rules or school. Acknowledge the concern, tie it back to trust and promise it a place in Task 5. Illustrative: "We will get to curfew. Right now, if she doesn't trust you, any rule becomes a fight." [source: Diamond et al. 2016 (principle); wording synthesis]
Parent defends, belittles, blames or distances in Task 4. These patterns marked unsuccessful sessions. Interrupt early, block the defence, ask the parent to reflect back what they heard; if it continues, stop the conjoint conversation, take the parent alone briefly (return to Task 3 work) and resume later. Enmeshed responses (over-apologising, making it about the parent's own pain) also need redirecting to the youth's experience. [source: Stern, King & Diamond 2023 abstract (patterns); responses synthesis]
Parent's capacity for attunement is limited (own depression, trauma, substance use, active conflict). Real conversations must account for this; do more Task 3 work, treat or refer the parent, choose a smaller rupture first, or involve another caregiver. [source: Diamond et al. 2016 (limit noted); responses synthesis]
Youth refuses to talk with parents or protects them ("don't want to burden" her). Explore the fear, increase entitlement to voice, start with a lower-stakes topic, and let the youth see that parents have been prepared. Do not force Task 4. [source: E2 training slides; ABFT/CAMS 2023 deck (entitlement, convincing); pacing synthesis]
Stuck in rejecting anger or flat withdrawal. Interpretations, reassurance and focusing on rejecting anger tended to stop productive emotional processing; relational reframes and attention to primary adaptive emotion tended to start it. Shift from the anger to the hurt and need beneath it. [source: Tsvieli et al. 2020 abstract]
Overwhelm or flooding (youth or parent). Slow pace, ground, narrow the focus, shorten disclosure, return to individual sessions; in suicidal youth re-check risk and the safety plan before ending. [synthesis]
Suicidal crisis or self-harm during treatment. Revisit safety planning (4.0): means restriction, monitoring, crisis line, twice-weekly sessions; involve caregivers; arrange higher levels of care when indicated, following standard risk-assessment practice. [source: ABFT/CAMS 2023 deck; escalation steps synthesis]
Disclosure of abuse or ongoing harm by a caregiver. Conjoint attachment work is not the first step: follow mandated-reporting and child-protection duties, ensure safety, and decide with the protective team whether, when and with whom repair work is appropriate. [synthesis; sources do not address this]
Early drop-out and non-attendance. Low-income families often show high early attrition. Respond quickly to referrals (the inpatient adaptation used same-day response), offer home-based or online sessions, coordinate with schools and other services, and contact families after a missed session. [source: Diamond et al. 2016; CEBC; outreach steps synthesis]
No homework is used, so 'non-adherence' mainly means missed sessions or parents not applying emotion-coaching skills; review those skills at the start of conjoint sessions. [source: CEBC (no homework); response synthesis]
Rupture in the therapeutic alliance. Name it, take your share of responsibility, and repair openly; this models the repair the family is learning. [synthesis]
Separated, divorced or blended families. Decide which caregiver relationship holds the core rupture; Task 3 can be run separately with each caregiver; avoid making the youth a go-between. [synthesis]
Parental rejection of sexual or gender identity. Give parents more individual time to process disappointment, fear and grief; work toward acceptance; point out subtle invalidating responses before conjoint work; consider ABFT-SGM for young adults. [source: Diamond et al. 2016; APA ABFT-SGM page]
Therapist pulled to fix, reassure or avoid. Use supervision (person-of-the-therapist work); review recordings against task goals. [source: E2 training slides; ACF Clearinghouse (therapist issues); application synthesis]
Organisational barriers (leadership change, staff turnover, mandated rather than chosen participation). These undermined one implementation; secure management support and voluntary therapist uptake before adopting. [source: Diamond et al. 2016]

Sources

Sources: