Emotional arousal and reflective functioning among parents participating in attachment-based family therapy for LGBTQ+ young adults and their nonaccepting parents.

OBJECTIVE: Parents' rejection of their LGBTQ + young adults can have a negative impact on their young adult's psychological welfare, and on the young adult-parent relationship. Parents' ability to reflect on their child's pain and unmet needs is thought to evoke empathy and compassion, and reduce rejection. Empirical and clinical evidence suggest that parents' level of reflective functioning (RF) is impacted by their level of emotional arousal (EA). This study examined the association between parents' EA and RF within the context of attachment-based family therapy for nonaccepting parents and their LGBTQ+ young adults. METHODS: 43 therapy sessions drawn from six different cases were coded for parental RF and EA, based on 30-second segments. This generated a total of 343 observations for analyses. RESULTS: Hierarchal linear modeling revealed that parents' level of RF was a function of their concomitant EA, with moderate levels of arousal predicting the highest RF levels. CONCLUSION: Moderate EA may facilitate optimal parental reflective functioning. With nonaccepting parents, who typically present for treatment with high levels of maladaptive fear and shame, therapists would do well to assess their level of arousal and, when indicated, employ downregulating interventions before inviting them to reflect on their young adult's experience and needs.

Attachment-based family therapy for sexual and gender minority young adults and their nonaccepting parents.

This pilot open trial examined the efficacy of attachment-based family therapy (ABFT) for Israeli sexual and gender minority (SGM) young adults and their persistently nonaccepting parents. Thirty families received up to 26 weeks of treatment, with parental rejection, parental acceptance, and young adults' attachment avoidance and attachment anxiety assessed at baseline, 8, 16, 24, and 36 weeks (three months post-treatment). Analyses using multilevel growth models revealed that both young adults and their mothers independently reported increases in mothers' acceptance of their young adult's same-sex orientation or noncisgender identity. In addition, young adults reported decreases in both parents' levels of rejection. Also, mothers, but not fathers, reported decreases in their own level of rejection. Finally, young adults reported a decrease in attachment avoidance in their relationships with both mothers and fathers, but not a decrease in attachment anxiety. Importantly, these treatment gains were maintained three months after the end of treatment. Together, these results suggest that ABFT-SGM, a manualized, affirmative, experiential, family-based treatment, may be effective in reducing long-standing parental rejection, promoting parental acceptance, and improving the quality of LGBTQ+ young adults' relationships with their parents. These findings are encouraging in light of the urgent need for efficacious interventions to reduce family generated minority stress and promote safer, more supportive environments for sexual and gender minority people.

Parents' reflective functioning and their agreement on treatment goals in attachment-based family therapy for sexual and gender minority young adults and their nonaccepting parents.

This study examined the trajectories of parents' reflective functioning over the course of individual preparatory sessions with the therapist in attachment-based family therapy (ABFT) for Israeli sexual minority young adults and their nonaccepting parents, and whether such reflective functioning was associated with parents' agreement on the goals for subsequent conjoint corrective attachment sessions. Three parents with good agreement on treatment goals were compared to three parents with poor agreement on treatment goals. Parents' in-session reflectivity regarding their child's experience of nonacceptance, and regarding the quality of their relationship with their child, was observationally measured at the session level. Reflective functioning increased over time among those parents who reported good agreement with the treatment goals. There were no changes in parents' reflective functioning in the poor agreement group. Findings suggest the potential importance of facilitating parents' reflective functioning in ABFT, before conducting conjoint corrective attachment sessions. Research and clinical implications are discussed.

Corrective attachment episodes in attachment-based family therapy: the power of enactment.

Corrective attachment episodes, therapeutic enactments designed to increase openness and trust between young adults and their parents, are the purported primary change mechanism in attachment-based family therapy. This study examined whether sequences of therapist interventions, young adults' productive emotional processing, and parental behaviors thought to reflect corrective attachment episodes were characteristic of good versus poor outcome cases. Thirty conjoint attachment sessions were analyzed using the THEME algorithm. Results revealed that only in good outcome cases were there four-step sequences hypothesized to facilitate attachment. One sequence began with the therapist focusing on the young adult's primary adaptive emotions, followed by the young adult's productive emotional processing of their vulnerable emotions, followed by the therapist empathizing with and validating the parent, followed by parents' expressions of warmth toward their young adult. The second sequence began with the therapist focusing on the young adult's unmet attachment needs, followed by the young adult productively processing their vulnerable emotions, followed by the parent expressing a willingness to fulfill their young adult's attachment needs, followed by parents' expressions of warmth toward their young adult. Findings provide an empirically-based clinical map for conducting therapeutic enactments in family therapy and have implications for treatment development, therapist training and supervision.

Attachment-based family therapy: Theory, clinical model, outcomes, and process research.

Attachment-based family therapy (ABFT; Diamond G.S. et al., 2014) is an empirically supported treatment designed to capitalize on the innate, biologically based, caregiving instinct and adolescent need for attachment security. This therapy is grounded in attachment and emotional processing theory and provides an interpersonal, process-oriented, trauma-informed approach to treating adolescents struggling with suicide and associated problems such as depression and trauma. ABFT offers a clear structure and road map to help therapists quickly address the attachment ruptures that lie at the core of family conflict, which can fuel adolescent distress. Several clinical trials and process studies have demonstrated empirical support for the model and its proposed mechanisms of change. In this paper, we provide an overview of the theories underlying the model, the clinical strategies that guide the treatment, the outcome research that demonstrates efficacy, and the process research that explores the proposed mechanisms of change.

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.

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.

Exploring the process of change in emotion-focused therapy for social anxiety.

Objective: This study examined purported change mechanisms in emotion-focused therapy for social anxiety disorder. Methods: The sample included nine clients who had participated in a multiple-baseline case study trial examining the efficacy of emotion-focused therapy for social anxiety disorder (SAD). Multilevel analyses were conducted to examine the trajectories of emotions over the course of treatment, and whether primary adaptive emotions in a given session predicted levels of SAD symptoms, self-criticism, and self-reassurance over the course of the following week. Results: Findings showed a significant decrease in shame, and a marginally significant increase in assertive anger, over the course of treatment. Adaptive sadness/grief in a given session predicted less fear of negative evaluation over the course of the following week. Shame in a given session predicted higher levels of inadequate-self over the course of the following week. Finally, shame, and to a lesser degree assertive anger, in a given session predicted reassurance of self over the course of the following week. Neither assertive anger nor adaptive sadness/grief in a given session predicted levels of self-criticism over the course of the following week. Conclusions: These findings lend partial preliminary support for the therapeutic role of evoking and processing adaptive sadness/grief and assertive anger in the treatment of SAD.

Measuring Adult Children's Perceptions of Their Parents' Acceptance and Rejection of Their Sexual Orientation: Initial Development of the Parental Acceptance and Rejection of Sexual Orientation Scale (PARSOS).

The Parental Acceptance and Rejection of Sexual Orientation Scale was administered to 256 self-identified lesbian, gay, bisexual, or queer adults who had been out of the closet to their parents for at least 1 year. Principal component analysis revealed a clear two-component solution: parental acceptance and parental rejection. Findings showed that perceived maternal sexual orientation-specific acceptance was higher, and perceived maternal sexual orientation-specific rejection was lower, for gay/bisexual sons compared to their lesbian/bisexual daughters. Results of regression analyses suggest that both perceived sexual orientation specific acceptance and rejection predicted adult children's psychological symptoms after accounting for perceived global parental acceptance and rejection and the child's gender. The scale's utility for research and practice are noted.

Therapist interventions and emotional processing in attachment-based family therapy for unresolved anger.

A growing body of research suggests that emotional processing is a central and common change mechanism across various types of therapies (Diener & Hilsenroth, 2009; Foa, Huppert, & Cahill, 2006; Greenberg, 2010), including attachment-based family therapy (Diamond, Shahar, Sabo, & Tsvieli, 2016). The purpose of this study was to examine which therapist interventions facilitated productive emotional processing in a sample of 15 young adults receiving attachment-based family therapy (Diamond, Diamond, & Levy, 2014) for unresolved anger toward a parent, and which therapist interventions led to a discontinuation of productive emotional processing once it had begun. Therapist interventions and productive emotional processing were measured during the course of individual, alliance-building sessions with the young adult. Results indicate that young adults' productive emotional processing occurred at a rate significantly greater than chance following therapists' focus on vulnerable emotions, focus on attachment needs, and empty-chair interventions. In contrast, therapists' focus on clients' rejecting anger preceded the discontinuation of such processing at rates significantly greater than chance. Theoretical and clinical implications are discussed. (PsycINFO Database Record

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.

Attachment-based family therapy and individual emotion-focused therapy for unresolved anger: Qualitative analysis of treatment outcomes and change processes.

Twenty-six clients who received 10 sessions of either attachment-based family therapy (ABFT) or individual emotion-focused therapy (EFT) for unresolved anger toward a parent were interviewed 6 months after completing treatment. Interviews were analyzed using the consensual qualitative research approach. Clients in both conditions reported improved relationships with parents, gaining a new perspective of their parent, increased compassion toward parent, less reactivity to anger, feeling cleaned-out, and acquiring new coping strategies. Whereas ABFT clients more often reported improved relationships with parents, EFT clients more often reported feeling cleaned-out. Clients in both groups attributed change to productive emotional processing. Also, clients in both groups attributed change to saying difficult things that had never been said before directly to parents, though more so in ABFT. Whereas ABFT clients noted the importance of their parents participating in treatment and mutual vulnerability, EFT clients noted the importance of remembering previously avoided memories and feelings, and getting their anger of their chest. While some EFT clients reported that therapy had a negative impact on their relationship with their parents and increased their anger, some ABFT clients reported that the positive impact of therapy during the active phase of treatment did not last, though there were no meaningful between-groups differences regarding these negative treatment outcomes and processes. Results are discussed in the context of previous quantitative findings from the same sample, and in the context of prior research on experiential and emotion-focused therapies. Implications for future research are noted. (PsycINFO Database Record

Attachment-based family therapy and emotion-focused therapy for unresolved anger: The role of productive emotional processing.

A growing body of research suggests that emotional processing is a central and common change mechanism across various types of therapies (Diener & Hilsenroth, 2009; Foa, Huppert, & Cahill, 2006; Greenberg, 2011). This study examined whether 10 weeks of attachment-based family therapy (ABFT), characterized by the use of in-session young adult-parent dialogues, were more effective than 10 weeks of individual emotion-focused therapy (EFT), characterized by the use of imaginal dialogues, in terms of facilitating productive emotional processing among a sample of 32 young adults presenting with unresolved anger toward a parent. This study also examined whether greater amounts of productive emotional processing predicted more favorable treatment outcomes. In contrast to our expectations, we found significantly more productive emotional processing in individual EFT than in conjoint ABFT. Results also showed that while both treatments led to significant and equivalent decreases in unresolved anger, state anger, attachment anxiety, and psychological symptoms, only ABFT was associated with decreases in attachment avoidance. Although amount of emotional processing did not explain the unique decrease in attachment avoidance in ABFT, greater amounts of productive emotional processing predicted greater decreases in psychological symptoms (but not other outcome measures) across both treatments.

Gender Atypicality and Anxiety Response to Social Interaction Stress in Homosexual and Heterosexual Men.

Gender non-conforming behavior and a homosexual sexual orientation have both been linked to higher levels of anxiety. This study examined the independent and interactive effects of gender atypicality and sexual orientation on levels of state anxiety immediately following a stressful social interaction task among a sample of homosexual and heterosexual Israeli men (n = 36). Gender atypicality was measured via both self-report and observer ratings. State anxiety was measured via both self-report immediately subsequent to the stressful social interaction task and pre- to post task changes in salivary cortisol. Results showed that self-reported gender atypicality and heterosexual sexual orientation predicted higher levels of self-reported social interaction anxiety, but not changes in cortisol. There were no sexual orientation by gender behavior interactions and there were no significant effects for observer rated gender atypicality. These findings suggest that gender atypicality, not homosexuality, place individuals at risk for increased anxiety.

Causal Attributions and Parents' Acceptance of Their Homosexual Sons.

This Internet-based study examined the association between Israeli parents' attributions regarding the cause of their son's homosexuality and their level of acceptance of their homosexual son. The sample (N = 57) was recruited via Internet Web sites (gay forums and support groups). Findings suggest that more essentialist (versus constructivist) causal attributions were associated with higher levels of parental acceptance. Length of time parents knew of their son's homosexual orientation predicted the degree to which their attributions were essentialist. Implications are discussed.

25 years of systemic therapies research: progress and promise.

OBJECTIVE: In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of therapeutic change in couple and family systems. METHOD: We begin by explaining how we view "systemic therapies" as different from individual approaches and then summarize what we have learned in the past 25 years about this set of treatments, how we have learned it, and what we have yet to learn. RESULTS AND CONCLUSIONS: We consider current trends in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the interrelated domains of systemic research and practice.

Lessons offered, lessons learned: reflections on how doing family therapy can affect therapists.

Only in working conjointly with couples and families do therapists literally witness clients struggling to improve their most intimate relationships. In writing this article, we realized that, in true systemic fashion, not only have many of our clients benefited from working with us, but also we have learned some invaluable lessons from them. Indeed, practicing couple and family therapy gives therapists many opportunities to learn about themselves, especially when it is done thoughtfully. In this article, we reflect on myriad ways in which couples and family therapy has affected each of us personally-as individuals, as partners, as parents, as adult children in our families of origin, and as educators.

Good versus poor therapeutic alliances with non-accepting parents of same-sex oriented adolescents and young adults: a qualitative study.

OBJECTIVE: Therapeutic themes and processes associated with five good versus five poor parent-therapist alliances among a sample of non-accepting parents of sexual minority youth/young adults participating in family therapy were examined. METHOD: The Consensual Qualitative Research approach was used to analyse of therapy notes and follow-up interviewsfrom good and poor alliances. RESULTS: In good alliances, parents adopted relationship building as a goal, considered essentialist causal attributions of same-sex orientation, acknowledged positive aspects of their child, and perceived the therapist as empathic and accepting. Parents with poor alliances rejected relationship building as a goal, rebuffed essentialist causal attributions, dismissed the possibility of their own coming out, nullified positive aspects of their child, sought to change their child's sexual orientation, blamed therapists for validating their child's same-sex orientation, and pressured therapists for information about their child. CONCLUSIONS: Clinical implications are discussed.

Attachment-based family therapy interventions.

Attachment-Based Family Therapy is a treatment model designed specifically for depressed and suicidal adolescents. The primary goal of the treatment is to promote developmentally appropriate adolescent-parent attachment. Three core interventions are discussed: relational reframes; focusing on primary emotions and unmet attachment needs; and facilitating corrective attachment episodes. For each intervention, the theoretical/clinical rationale is presented followed by a brief illustration and relevant research findings.

Changes in parenting behaviors, attachment, depressive symptoms, and suicidal ideation in attachment-based family therapy for depressive and suicidal adolescents.

This study examined whether Attachment-Based Family Therapy (ABFT) was associated with decreases in maternal psychological control and increases in maternal psychological autonomy granting, and whether such changes were associated with changes in adolescents' attachment schema and psychological symptoms. Eighteen suicidal adolescents and their mothers received 12 weeks of ABFT. Maternal psychological control and autonomy granting behaviors were observationally coded at sessions 1 and 4. Adolescents' reports of perceived maternal care and control, attachment-related anxiety and avoidance, and depressive symptoms and suicidal ideation were collected at baseline, 6, 12 weeks (posttreatment), and 36 weeks. Results indicated that from session 1 to session 4, maternal psychological control decreased and maternal psychological autonomy granting increased. Increases in maternal autonomy granting were associated with increases in adolescents' perceived parental care from pre to mid-treatment and decreases in attachment-related anxiety and avoidance from pre to 3 months posttreatment. Finally, decreases in adolescents' perceived parental control during the treatment were associated with reductions in adolescents' depressive symptoms from pretreatment to 12 weeks posttreatment. This is the first study examining the putative change mechanisms in ABFT.