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A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal
Open accessAbstract
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; F 1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t 127 = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t 127 = 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.
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“Based on previous trials [21, 23], we estimate a 35% dropout rate.”
From The effectiveness and cost-effectiveness of attachment-based family therapy for young adults with high suicidal ideation: protocol of a randomized controlled trial (2024) · cites this paper as [23]
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“Several studies have demonstrated the effectiveness of ABFT for adolescents and young adults at risk for suicide [26–28].”
From Evaluating attachment-based family therapy in residential treatment in the United States: does adolescents' increased attachment security to caregivers lead to decreases in depressive symptoms? (2024) · cites this paper as [27]
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“However, effectiveness studies have shown mixed results on suicidal ideation [21, 23, 28, 29].”
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“For example, two randomized controlled clinical trials in the United States were conducted with samples in which a large percentage of teens (74% in the first trial and 49% in the second trial) identified as Black/African American (48, 62, 63), a group in the United States that has been historically marginalized and very likely to contend with race/ethnicity-related stress and trauma.”
From Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety (2023) · cites this paper as [48]
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“Including ABFT in the treatment of adolescent anxiety may be particularly beneficial for adolescents from historically marginalized communities, as ABFT was originally developed with these populations in mind (48–50).”
From Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety (2023) · cites this paper as [48]
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Citations
Cites
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Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients
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SHAFFER, D., FISHER, P., LUCAS, C. P., DULCAN, M. K., & SCHWAB-STONE, M. E. (2000) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200001000-00014 · Cited by 3,505 · cited 2×
“nonsuicidal self-injury as indicated by the ColumbiaSuicide Severity Rating Scale (C-SSRS).(18) At intake, 41.”
BackgroundMethodJacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, J. B. (1999) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.67.3.300 · Cited by 853
Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, J. B. (1999) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.67.3.300 · Cited by 853 · cited 2×
“The methodology of Jacobson et al.(29) was used to assess reliable change.”
MethodBrent, D. A. (1997) · Archives of General Psychiatry · doi:10.1001/archpsyc.1997.01830210125017 · Cited by 753 · cited 3×
“In a study of adolescents with major depressive disorder, cognitivebehavioral therapy (CBT) proved more effective than systemic behavior family therapy or NST in decreasing depressive symptoms.(5,11) However, Brent et al.”
BackgroundHow central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis.
Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012) · Journal of Counseling Psychology · doi:10.1037/a0025749 · Cited by 576 · cited 1×
“Second, the 2 treatments were delivered in a highly regarded children’s hospital and university, which engenders the kind of institutional alliance that has often been associated with better outcomes.(43) Testing these treatments in real-world clinical settings might be needed to evaluate their true clinical value.”
BackgroundOugrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. R. (2015) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2014.10.009 · Cited by 508 · cited 3×
“This compares favorably to a meta-analysis that failed to find significant decreases in suicide attempts when active interventions were compared with TAU.33,34 In the Treatment Study of Adolescent Suicide Attempters (TASA),35 consisting of medication plus CBT plus family, 12% of participants made an attempt within 6 m…”
ResultPrinstein, M. J., Nock, M. K., Simon, V., Aikins, J. W., Cheah, C. S. L., & Spirito, A. (2008) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.76.1.92 · Cited by 435 · cited 1×
“These criteria establish a common clinical presentation and increased risk for suicide attempts.(13,14) Seventh, this study incorporated a diverse racial and ethnic sample, providing a test of the generalizability of treatment effects across race and social class.”
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Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth
Glenn, C. R., Esposito, E. C., Porter, A. C., & Robinson, D. J. (2019) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2019.1591281 · Cited by 219
“RCT replication was less helpful for the status of Psychodynamic Therapy–Family-Based, “brand name” ABFT (Diamond et al., 2018, 2010), which is now rated as Level 4: Experimental for reducing SI and SA in youth.”
InfluentialSuicide and Suicide Risk in Adolescents
Hua, L. L., Lee, J., Rahmandar, M. H., Sigel, E. J., COMMITTEE ON ADOLESCENCE, & COUNCIL ON INJURY, V. (2024) · Pediatrics · doi:10.1542/peds.2023-064800 · Cited by 205
Kothgassner, O. D., Robinson, K., Goreis, A., Ougrin, D., & Plener, P. L. (2020) · Borderline Personality Disorder and Emotion Dysregulation · doi:10.1186/s40479-020-00123-9 · Cited by 163
Interventions for self-harm in children and adolescents
Witt, K. G., Hetrick, S. E., Rajaram, G., Hazell, P., Taylor Salisbury, T. L., Townsend, E., & Hawton, K. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013667.pub2 · Cited by 149
Attachment-based family therapy: Theory, clinical model, outcomes, and process research
Diamond, G., Diamond, G. M., & Levy, S. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.07.005 · Cited by 91
Self-citation
Metadata
- Authors
- Diamond, G. S., Kobak, R. R., Krauthamer Ewing, E. S., Levy, S. A., Herres, J. L., Russon, J. M., & Gallop, R. J.
- Affiliations
- Drexel University (US)
- University of Delaware (US)
- The College of New Jersey (US)
- Virginia Tech (US)
- West Chester University (US)
- Corresponding author
- Diamond, Guy S.
- ORCID
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2019-07
- Volume
- 58
- Issue
- 7
- Pages
- 721-731
- ISSN
- 0890-8567 (ISSN-L)
- PMC
- PMC6491252
- OpenAlex
- W2898714608
- Cited by
- 147
- References
- 45
- Citations by year
- 2026: 13 · 2025: 19 · 2024: 13 · 2023: 24 · 2022: 15 · 2021: 41 · 2020: 9 · 2019: 11
- FWCI
- 17.92
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- VTechWorks (Virginia Tech) (submittedVersion, public-domain)
- Funders
- National Institute of Mental Health (5R01MH091059-03)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Counseling, Therapy, and Family Dynamics
- Keywords
- attachment-based family therapy, suicidal adolescents, suicidal ideation, depressive symptoms, family therapy, treatment efficacy, regression to the mean, African American adolescents
- MeSH terms
- Adolescent, Child, Depression, Family Therapy, Female, Humans, Male, Object Attachment, Pennsylvania, Suicide, Attempted, Reactive Attachment Disorder, Self Report, Suicidal Ideation
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