Attachment-based family therapy’s goal is to repair the bond in the parent-child relationship. Attachment therapy has been shown to be effective with children and adolescents and is based on John Bowlby’s attachment theory. This modality is emotion focused and empirically supported.
Background of Attachment-Based Family Therapy (ABFT)
Attachment theory was initially developed by John Bowlby and then further developed by Mary Ainsworth. Attachment was defined by Bowlby as the “lasting psychological connectedness between human beings.” According to this research, from about the age of six months on, children began to form attachments to primary caregivers and other family members. There are four types of attachment proposed by attachment theory.
Ambivalent attachment: Children who become markedly upset anytime a parent leaves. In attachment-based family therapy, this typically occurs when children learn they cannot depend on their caregivers to take care of them when they need them.
Avoidant attachment: These children actively avoid parents and have no preference between parents and a random adult. This behavior is typically linked to abuse or neglect from parents or caregivers. Because these children have experienced negative consequences for relying on caregivers, they learn to avoid looking to others for help.
Disorganized attachment: These children have no clear attachment pattern. They may avoid connections or outright resist them. Often, these children have grown up in homes where caregivers were sometimes a source of comfort and at other times, the source of fear.
Secure attachment: These children have learned they can depend on their caregivers and show happiness when they are reunited with parents. They become upset when parents leave, but don’t fear that they will return. They seek assurance from caregivers and are able to form healthy attachments in relationships as they age.
While these attachment-based family therapy styles won’t look the same in adulthood as they do in childhood, there is evidence that shows that unless attachment difficulties are resolved, then adults will continue to experience a pattern of relational difficulties in all relationships they are involved in.
ABFT Therapy techniques, tasks, and timeline
Attachment-based family therapy is what is known as manualized therapy, meaning that there is a specific structure and certain tasks to complete in order to repair the attachment.
Typically only one session with the goal of changing the focus away from current identified problems and short towards beginning to understand how trust was damaged.
Adolescent alliance building
Generally lasts about two sessions. The therapist works individually with the adolescent and learns about strengths. Here, the therapist also teaches the child how to speak about the damage that has occurred in their relationship.
Typically lasts two sessions where the therapist meets only with the parents to uncover any attachment-related problems and how they may be affecting their relationship with their child.
Resolving attachment ruptures
May be anywhere from one to four sessions. In this task, the goal is to prove corrective experiences and allow the child and parents to discuss concerns in a regulated manner with empathy. This task sets the expectations for experiences going forward.
Promote a healthy parent child relationship
This final task allows the child to develop needed autonomy while also helping parents find the balance between support and allowing the child to develop appropriate levels of responsibility.
Who is the target in attachment-based family therapy?
Because attachment-based family therapy identifies the primary problem as a breakdown in the connection between individuals, this therapy requires whole family involvement. Neither the child alone, nor the parents on their own can complete the tasks required for successful completion of ABFT.
Different tasks of ABFT target either the parents, the child alone, or the whole family. However, a parent cannot complete the therapy alone and neither can a child.
Empirical studies have proven ABFT effective for adolescents and their families struggling with depression and suicidal behaviors. Additionally, limited studies have shown a decrease in anxiety concerns.
Families who have completed the program have reported improvements in the family relationship which improve home life in general. More studies with varied populations are expected to show the effectiveness of this program when followed to fidelity.
ABFT is an empirically supported treatment included on the National Registry of Empirically Proven Practices. However, as with all types of therapy, it also has some limitations.
The first problem is that the majority of the research has been completed with low-income adolescents and their families. It is assumed that since attachment theory principles have been proven effective across the board, that this protocol would also be effective. However, that has not yet been studied.
The tasks themselves are lacking in understanding. They haven’t been studied deeply on their own to allow for limitations and concerns to arise and be addressed.
Additionally, with any manualized treatment, there is always the concern that someone may go ‘off book’ and negatively affect outcomes. ABFT developers have attempted to address this concern with the supervision requirements, however, the concern always exists.
The final limitation of course is that it requires full cooperation of the parents and the child. If anyone in the group is not participating appropriately, then the protocol will produce limited results. This is a limitation present in all therapies based in groups or families and is not a difficulty of this program alone.
Insurance coverage for Attachment-Based Family Therapy(ABFT)
Attachment-based family therapy is, first and foremost, family therapy. It would be covered under CPT code 90847, Family therapy with the patient present. If billing under the child’s insurance, only then task three sessions that do not include the child. They would need to be billed under 90846: family therapy without a patient present. 90847 and 90846 both must be a minimum of 26 minutes long to qualify for billing. However, if a session is extended, then there are add-on codes. It is important to check with each insurance company that you are paneled with because not all insurance companies consider family therapy a routine service. Some insurance coverage will only allow payment for it under very specific circumstances that must be documented appropriately.
How does it compare to other prominent family therapies
ABFT is the only family therapy model that is both empirically supported and manual based to ensure consistency across practices.
While other therapies such as family systems therapy may focus on the family as a unit, no other therapy focuses specifically on the family relationship as a way to treat depression and reduce the risk of suicidal behaviors in teens.
Primary client profile
ABFT was designed as a treatment modality for families trying to manage adolescents experiencing depression and suicidality. However, the belief is that it can help individuals cope with a multitude of other concerns. There is limited evidence that anxiety can also be reduced with effective attachment work between family members.
The primary fact to remember is that ABFT requires the parents and child to be successful. Without all parties involved, it isn’t truly ABFT and may not have the improvements typically seen in families following protocol.
Issues to be solved
The primary focus of attention in ABFT is the core conflicts in the family. This can include attachment issues the parents have yet to resolve causing interactional difficulties in the family, misunderstandings based on emotional immaturity and inability to communicate effectively, as well as any other problem that is impacting the parent-child attachment. While the main focus has been improving relationships for adolescents who are struggling with depression and thoughts of suicide, many families find that the entire family shows improvement with the repair of the family connection.
Special training for the therapist
As a manualized training, therapists must undergo specific training and then submit tapes to supervisors to ensure they are completing tasks in the appropriate manner.
- Levels 1 and 2 require workshop training.
- Level 2 also requires supervision.
- Level 3 is the certification level.
Training is offered by the developers and is available to a number of individuals in the mental health and helping field. Counselors, psychiatrists, psychologists, marriage and family therapists, and social workers are all qualified to be trained in the program.
Attachment-Based Family Therapy(ABFT) resources.
Anyone wishing to delve deeper into the empirical research that supports this therapy program as well as other relevant research information, see the article here.
Counselors working with clients in attachment-based family therapy can rely on tools such as TheraPlatform to store and manage all aspects of documentation including progress notes and treatment plans. Save time and money on private practice administrative tasks with automated scheduling and claims as well as a dedicated client portal and teletherapy. They also offer a 30-day trial with no credit card required. Cancel anytime.
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