ATTACHMENT-

BASED
FAMILY THERAPY
An Introductory Workshop

Center for Family Intervention Science

ABFT Training Program
• Guy Diamond, Ph.D., Director
• Associate Professor, College of Nursing and Health
Professionals, Drexel University

• Gary Diamond Ph.D.,

• Professor and Chair of the Department of Psychology, Ben Gurion
University, Israel

• Suzanne Levy, Ph.D., Training Director

• ABFT Training Program, Drexel University, College of Nursing
and Health Professions ([email protected])
• Websites:
 www.ABFTtraining.com
 www.facebook.com/Attachment.Based.Family.Therapy
 Gary Diamond’s Research: http://www.bgupsychotherapyresearch.org/
 Follow us on Twitter @ABFTtraining and Youtube
 Belgium ABFT Training Center: https://ppw.kuleuven.be/ogop/abft

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 Overview of ABFT
 Studied as a 12 to 16 week treatment
 Developed for depressed and suicidal adolescents
 Built around 5 distinct yet interrelated treatment “tasks”
 Manual is focused but flexible
 Based in Attachment Theory and Structural Family Therapy
 International and National Registries
 The National Registry of Evidence-based Programs and
Practices (NREPP) has determined that ABFT is a program with
effective outcomes.
 ABFT is classified as a “proven practice” on the Promising
Practices Network (PPN) run by the Rand Corporation
 Listed in the Swedish Guidelines for treatment of depression
 CYP IAPT recommended evidenced based treatment in England

Securely attached families

Theory of Normative
Functioning

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 Secure Attachment
 Attachment Theory (Bowlby):
 When children experience parents as available, responsive,
and attuned to their emotional needs, they feel more
confident that
a) Parents will love and protect them
b) They are worthy of love and protection.

 Over time, the child’s expectation of the parents’ availability

becomes internalized as a working model or schema of what
to expect in relationships.

 Attachment is cross-cultural

Development of Emotional Regulation

Child feels Attachment Turn to

Child’s fears
scared or needs get parents for
are calmed
threatened activated protection

Over time, self soothing is internalized,

thus promoting emotional regulation skills

Parenting Skills that

Promote Affect Regulation
 Acceptance of negative emotion
 Validation
 Coaching
 Teaching an emotional vocabulary
 Conflicts resolved through negotiation and
compromise rather than submissiveness and
disengagement

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 Authoritative Parenting
(Diane Baumrind)
 High on warmth (love and acceptance)
 High on structure (supervision, monitoring)
 Support for autonomy (demandingness)
 Tolerance for expression of ideas
 Promote expression of feelings
 More democratic parenting style
 Good cross cultural support
 Contextual modifications: Inner city, urban, SES

 Contrast with authoritarian or permissive style

Attachment in Adolescence
 Normative adolescent development occurs in the context of
supportive and respectful adolescent-parent relations

 Central task of adolescents: Develop autonomy while

maintaining a backdrop of attachment

 Moderate degree of conflict is normative and serves to

promote identity formation when it does not threaten secure
base.

Benefits of Attachment in
Adolescence
 Securely attached adolescents can:
 Reflective functioning
 Self reflect
 Perspective taking
 Express vulnerable emotions in a regulated manner
 Feel confident that they can express dissatisfaction with
parents or concerns in life without
 Fear of reprisal from parents
 Over burdening parents
 Fundamental trust that parents care about them and will
protect them

 Attachment is negotiated through conversation,

not behavioral control

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 Adolescence – Critical Period
 Normal process of maturing
 Brain development
 Puberty
 Peer and romantic relationships
 School problems (relational or
academic)

 Changes in family relations

 Parental developmental milestones

Theory of Pathology

Depression, Suicide and Trauma

in Adolescence
 11% of adolescents have a depressive disorder by age
18

 Suicide:2nd leading cause of death for young people

ages 15 to 24 years in the USA.
 Including non-lethal attempts, approximately 2,000,000
teenagers attempt suicide each year

 Adolescents who have experienced trauma as a child

are more likely to:
 Develop anxiety-related disorders and fears
 Display risky sexual behaviors
 Have an increase in risk-taking behaviors

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 Insecure Attachment
 Low expectation of parental availability for support and
protection

 Develop relational styles that defend against further

disappointment
 Avoidant (Dismissive): Deny the need for love and comfort
 Anxious (Preoccupied): Excessive concern with closeness
yet strong fears of abandonment
 Disorganized (Unresolved): No clear or cohesive strategy
for regulating attachment needs.

Attachment Style and Parenting

 Dismissive:
 Discomfort with closeness and intimacy
 Rebuff or ignore the child’s attachment needs
 Preoccupied:
 Psychologically preoccupied
 Inconsistent in their responsiveness
 Unresolved:
 Most chaotic parents
 Often source of fear and trauma
 When those from whom you expect comfort and protection
become your victimizers

Risk Factors for Insecure Attachment

 Life events - trauma
 Neglect, abandonment, physical or sexual abuse, deaths,
illness

 Parental Stress (leading to decreased parental

availability)
 e.g., Poverty, racism/discrimination, social injustice, lack of
support, marital stress

 Family interaction patterns

 High conflict/low cohesion, parental high control/ low affection,
parental criticism
 Intergenerational Transmission
 Child temperament, psychopathology, medical illness

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 An example of a small “t”

Attachment Based Theory of Adolescent

Depression and/or Suicide
ADOLESCENT PARENT

Intergenerational
Emotional Attachment Patterns:
Dysregulation Dismissive,
Preoccupied,
Unresolved
Attachment Insensitive
Ruptures Caregiving
Conflict over
Attachment and Psychopathology:
Other
Autonomy Depression,
contributing
factors Substance Use,
Personality Disorder

Dismissive,
Preoccupied, Current Stressors:
Unresolved Marital Problems,
Economic or
Contextual
Depression and/or Suicide

Theory of Change

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 Can we repair
insecure attachment?
 How stable are internal working models, or attachment
schemas?

 Attachment can move from secure to insecure (e.g. child

sexual abuse).

 Can attachment move from insecure to secure?

 Premise of our profession

Earned Security(Main & Goldwyn, 1988)

 Through positive relationships as an adult, one could earn
back a secure attachment style:
 An internal psychological working through, coming to terms,
gaining perspective, forgiving process

 Different ways to achieve this:

 Good marriage, friendships, etc.
 Individual Psychotherapy: Where the therapist provides the
safe haven to help the patient work though attachment injury
and regain trust.

Family treatment as unique

learning environment
 Having conversations about attachment ruptures with
one’s parents has an unique existential potency
 Acknowledgment from those causing the rupture
 Opportunity for apology and forgiveness
 Corrective attachment experiences
 Direct challenge to relational expectations
 Depression and suicide as relational events
 Strengthen connections - Potentiate protective factors

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 Where we fit in the world of
Psychotherapy and Family
Therapy

World of Family Therapy

PARENT CHILD

Psychoanalysis
(Neutral) Internal and
Historical

Family Therapy
(Authoritarian) Interactional and Current

Narrative
(Client Centered) Internal, Historical

Attachment Based Family Therapy

PARENT Relationship CHILD

Historical, interaction, and internal

Therapist is authoritative

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 Empirical Support

Empirical Support
 ABFT has shown to be effective with
depressed and/or suicidal adolescents in 6
studies

 Most recent published study: Youth Suicide

(Diamond et al, 2010) in Journal of the
American Academy of Child and Adolescent
Psychiatry.

2010 ABFT vs EUC Study

Suicide Ideation BDI Response: 50%
(SIQ) Reduction from
Baseline

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 Sexual Trauma & Response to
Treatment (2010 study)
Rate of Change on SSI
History of Sexual Trauma No History of Sexual Trauma

• Youth with sexual trauma history have poorer responses to depression treatment
(Asarnow et al., 2009; Barbe et al., 2004; Lewis et al., 2010)
•ABFT superior to EUC regardless of sexual trauma history
• Sexual trauma history did not moderate ABFT’s effect on suicidal ideation
• No interactions over time

2010 Study – Treatment attendance

Total Number of Therapy Sessions

11.0

12
10
# of Sessions

EUC
8 3.6 ABFT
6
4
2
0

Standard Deviations: 4.1 EUC; 4.2 ABFT

p < .001

ABFT vs NST 2016 Study

SIQ Scores

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 Take Away? 1
0.9
0.91 Cohen d
0.8
0.7
0.6
Comparison of 0.5
0.4 0.29
effect size in other 0.3
0.2
0.22
0.15
studies 0.1
0
0.04 0.02 0.02

Pct Change
100% 80.0%
80% 64.1% 61.2%
Percent SIQ 60% 47.1% 46.8%
40% 33.8% 29.9%
23.2%
Reduction for 20%
Active Intervention 0%
Pre to Post

2016 Study Conclusions

 Both treatments:
 Can help reduce suicide ideation in adolescents.
 Can be delivered by trained community therapists.
 Could be delivered in a regular, weekly outpatient or private
practice setting.

 Demonstrates the importance of the power of the common

therapy factors (e.g., alliance, relationships formation).

 Why still learn ABFT?

 ABFT did better than NST for suicidal ideation and depression,
when youth reported higher disengagement from parents.
 ABFT showed more reduction in family conflict than NST.

Other Research Studies

 Treatment of LGBT youth with suicide ideation (Diamond et
al, 2012)
 Aftercare for adolescents leaving the psychiatric hospital
after a suicide attempt
 ABFT compared to individual EFT for young adults with
unresolved anger towards parents.
 Training of therapists in a community agency in Norway.
(Israel & Diamond, 2012)
 Over 15 process research studies looking at the within
session processes associated with change

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 Dissemination Efforts
Internationally in: Nationally in:

• Australia • Arkansas • Minnesota

• Belgium • California • New Jersey
• Canada • Colorado • New York
• England • Delaware • Oregon
• Germany • Florida • Pennsylvania
• Iceland • Georgia • Texas
• India • Illinois • Utah
• Ireland • Indiana • Virginia
• Israel • Kansas • Washington
• Norway • Massachusetts D.C
• Sweden
• Turkey

The ABFT Model

We stand on the
shoulders of giants
 Structural family therapy Salvador Minuchin

 Multidimensional FT Howard Liddle

 Emotionally focused therapy Leslie Greenberg

Susan Johnson

 Contextual family therapy Ivan Boszormenyi-Nagy

 Attachment theory John Bowlby

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 ABFT Treatment manual
 Not a set of rules but a set of principles
 Goal Driven
 Flexible in how one reaches the goal
 Intentionality, intentionality, intentionality
 The person of the therapist remains central

Clinical Stance
 Client respectful, not client centered
 Scientist-Practitioner approach:
 We use our knowledge of psychological
science and family psychology to guide our
interventions
 Research on ideal parenting and specific
processes guide our work.

Five Treatment Tasks

• Relational reframe
• Adolescent Alliance
• Parent Alliance
• Attachment
• Promoting Autonomy

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 Suicide Management
 Several measures used to assess suicide risk at intake
(SSI, SIQ, CSSRS, SIS, Reasons for Suicide, Lethality
Scale)
 Clinical measures used during the course of therapy
(SIQ, BDI, CSSRS if increased risk).
 Family generated Safety Plan completed at intake and
updated as necessary
 If there is a safety concern, family is involved in
maintaining safety
 Suicide ideation discussed during various tasks of
therapy

Safety Plan review

 Safety plan is developed at intake and reviewed as necessary with
the family
http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf
 Warning signs (thoughts, images, mood, situation, behavior) that a
crisis may be developing?
 Internal coping strategies – Things I can do to take my mind off my
problems without contacting another person (relaxation technique,
physical activity)?
 People and social settings that provide distractions?
 People whom I can ask for help?
 Professionals or agencies I can contact during a crisis?
 Therapist assess use of safety plan
 Remove items that have not been helpful
 Add items that may be helpful

Before and After ABFT

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 Task 1: Relational
Reframe

Three Phases of the

Relational Reframe Task
 Phase 1: Joining and Understanding the
Presenting Problem Narrative (e.g., Depression
and/or Suicide)

 Phase 2: Shifting to Attachment Themes

 Phase 3: Contracting Relational Goals

Phase 1: Joining and Understanding

the Presenting Problem
 Joining
 Strengths of family members
 Context of the adolescent’s life (e.g., demographics, family,
school, peers, etc.)

 Assess the presenting problem (e.g., depression and/or

suicidal ideation)
 Need some details, but not a lot at this point and do not get
at all into problem solving.
 Get the adolescent on record as feeling miserable

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 Phase 2: Shifting to
Attachment Themes
 The mechanism of this Task: Relational Reframe

 Shifting from patient as problem to family

relationships as solution
 New content: From behavior management to the
parent-adolescent relationship
 New Affect: From secondary to primary emotions
 Activate caregiving instinct in parents and
attachment instincts in adolescents which leads to a
desire to be (re)connected.

Relational Reframe
 Sequence of conversation leading to agreement on
relational goals of therapy
 Identify ruptures
 “Do you go to your parents for help when you feel
so bad”
 “Why not?”
 Mark the consequences
 “Mom, it must be upsetting that he does not come
to you.“
 Amplify longing for connection
 “Johnny, I know you are (mad, sad, guarded), but I
bet part of you misses your mother as well.”

Phase 3
Contract for Relational Repair
 Therapist makes a clear request for agreement on a
treatment plan initially focused on relational repair and
enhancement
 When the therapist helps family members connect to their
natural desire for connection and love, it motivates family
members to accept the treatment plan

 Explore resistance and scale back goals if needed.

 Therapist lends the family hope
 “ I can help you two rebuild love and trust if you put the
work in that needs to be done.”

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 Task 2: Adolescent
Alliance

Task 2:
Alliance with the Adolescent
 Bond: Getting to know the adolescent

 Goals: Identifying relational ruptures and amplifying

entitlement to address felt injustices

 Task: Prepare adolescent for attachment task

Task 2: Bond
 Client moves from suspicion to comfort

 Explore adolescent’s life (romantic relationships,

sexuality, drugs, peers, hobbies, friends, also –
values, beliefs, hopes, dreams, etc.)

 Highlight strengths and competencies as

appropriate.

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 Task 2: Goals – Presenting Mental
Health Problem Narrative
 Explore and understand the adolescent’s mental health
presenting problem narrative (e.g., depression and/or
suicide narrative).
 External (details): History, precipitants, causes, worst it’s
been, solutions
 Internal (affect): How they feel? Deepen the emotion.
 Reflexive (meaning-making): What does this mean?

Process: Help summarize the story, build a timeline and

bring coherency.

Task 2: Goals-
Attachment Narrative
 Identify attachment ruptures.
 What gets in the way of using your parents as support
(ruptures)?

 Examples of ruptures:
 Traumatic events
 “My mom didn’t protect me when dad was abusing us. How can
I trust her now?”
 Negative family interactions
 “My dad does not accept me.”
 “My mom is critical and controlling.”
 “My parents don’t understand me and try to solve my problems.”
 Parental psychopathology
 “My mom freaks out (anxious) when I tell her my problems.”
 “I don’t want to burden my mom, she has enough on her plate.”

Attachment Narrative Cont’d

 Identify consequences of each rupture (external &
internal)
 Help adolescent access vulnerable emotions resulting
from the ruptures and consequences.

 Connect the ruptures to larger “attachment” themes

(trust, protection, abandonment, etc. – meaning-making)

Process: Help summarize the story, build a timeline and

bring coherency

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 Task 2: Goal – Adolescent
Motivation
 Link the presenting problem and attachment narrative
 Direct Link
 Indirect Link
 Goal:
 Amplifies adolescent’s entitlement to be heard
 Reactivates Attachment System: Desire for love and
protection
 Supports agreement for the attachment task

Working with Resistance

 Roll with resistance
 Adolescent is concerned about burdening the
parent:
 Why don’t you deserve to have these things addressed?
 These things are killing you, they are driving you to self-
destruction, you deserve to be heard.
 What you are doing is causing your parents more pain. Your
parent will grieve for the rest of his/her life if you take yours.

 Adolescent is concerned his/her parent won’t listen:

 You’ve never tried it with me. I can make it different. I can make
her listen. I will protect you.

 Adolescent is concerned there will be retribution at

home:
 Your concern is the first thing we will talk about with your parent.
Is it even safe for you to be honest?

Task 2: Task
Once the adolescent agrees, he/she must be
prepared:
 Choose, discuss & practice content for attachment
task
 Prepare for negative reactions
 Setting realistic expectations
 Therapist as a secure base

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 Anticipation of parental failure
 This may not happen in this task or at all
 Therapist helps the adolescent prepare for the
possibility that the parents fails to engage in the
attachment task effectively.

 Therapist helps the adolescent understand why it is

important that they engage in the attachment task,
even if their parent cannot do it well

Task 3: Parent Alliance

Task 3: Alliance With the Parent

 Bond: Getting to know the parent better

 Goals: Parental commitment to be there for their

adolescent in a different way

 Task: Prepare the parent for the attachment

task.

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 BOND: Outcome Goals
1. Build trust with parent
 have parent feel appreciated
 have parent see therapist as a resource
 Assure parent will not be blamed

2. Look for obstacles that inhibit relationship

building

3. Look for strengths that facilitate

relationship building

Bond: Exploring Current Stressors

 Explore sources of parental stress (e.g., divorce, marriage,
unemployment, health issues, discrimination, teens
presenting problem)

 Get parents to emotionally connect to their own struggles by

providing empathy

 Examine the impact of parent’s stress on their parenting

practices and/or adolescent

 Goal: Reduce parent blame and guilt by putting

parent-adolescent conflicts into context which
motivates parents for change.

Goal: Transitional Statements to link

stressors to parenting/adolescent
 Link to parenting:
 “You’re managing so many stressful things at once, how do you
think these things are impacting your parenting?”
 “It must be hard raising an adolescent, let alone a depressed one,
when you have so many other stressors in your life. How is that
impacting you?”
 “Wow, you are dealing with all this and your son. No wonder you
are not being the kind of parent you want to be. Tell me about
that.”

 Link to adolescent:
 “These financial difficulties are a huge burden on you, how do you
think all of these financial stressors are impacting your child?”
 “I know the fighting between the two of you has been difficult and
you’ve done the best you can to keep it from your adolescent.
Unfortunately the reality is that no matter how hard we try as
parents to hide that kind of stuff, adolescents usually know that
their parents are fighting. How do you think it has affected
him/her?

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 Bond: Intergenerational
Strategies
 Explore parent’s own childhood relationships with their
parents.

 Look for reoccurring intergenerational themes.

 Help the parents develop empathy for and connect to
their own attachment losses

Goal: Linking parents

attachment ruptures to parenting
 Can link regardless of parents own history
 “It was good.” Then it must be disappointing that you do not
have that with your daughter.
 “It was Bad.” Then you must know how painful it is to not have
your parents available to you.

 Help parents gain insight into:

 How their attachment relationship to their parent has impacted
their parenting
 How their adolescent feels as a result of their parenting
practices despite the parent’s caregiving intent
 Similarities between their own and their adolescent’s
experiences

GOAL: Activate caregiving instinct and desire to parent in

a more sensitive way which leads to agreement for the
attachment task

TASK: Preparing the Parent for the

Conversation
 Define the structure of the attachment task

 Prepare for reactions

 Orientation to emotion coaching skills

- Reflective Listening - Labeling emotions
- Validating - Being curious rather than problem-
solving

 Obtain permission to intervene and coach parents

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 Task 4: Attachment
Task

Shuttle Diplomacy
 Both parent(s) and adolescent are:
 Prepared for the conversation.
 Have identified important content areas.
 Have accessed more effective emotional states.
 Have agreed to have the conversation.

Attachment Task
 Goal: Engineer a corrective attachment experience.
 Adolescent experiences the parent as a positive attachment
figure which means someone who is caring, empathic, protective,
and responsive.
 Parents experience their child as having legitimate concerns and
being competent and regulated.

 Task: Facilitate discussion about core attachment

ruptures

 Process: adolescent uses new affect regulation and

interpersonal problem solving skills; parents use more
emotional coaching.

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 Mechanism of change:
Enactment (Process)
 In-vivo, experiential, real time conversation between
family members.

 Not teaching, not problem solving

 Therapists are as minimally involved as possible.

 If you have to help, get in and get out
 But you are sculpting the conversation: the content, the
affect and the process

Content is important
 Focus the conversation on the identified core
interpersonal or attachment ruptures
 Rather than on behavior/rules

 Don’t shy away from deep and difficult topics. Believe

in the family’s ability to apply what you taught them.
 Trust in the profound power of attachment instincts and
love to guide the family.

Affect is important
 Guide the family toward more primary emotions.
 Assertive anger
 Vulnerable emotions

 Therapy is more productive when the “fear structure” is

activated. The emotions that the adolescent or the
parents want to avoid the most: hurt, sadness,
appropriate anger, disappointment

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 Sustain the Emotional Moment
 Brings attachment to the forefront

 Exposure: patient and parents learn to tolerate

emotional arousal (habituation), and gain new
information that challenges the fear structure in
a safe environment

 Affect regulation: family members practice

managing intense emotions

Task 5: Promoting
Autonomy Task

Task 5:
Promoting Autonomy Goals
 Re-vitalize a goal corrected partnership (Bowlby)
 Cooperation emerges from desire to maintain connection
 Parents are now viewed as a secure base

 Build competency in communication skills between

parents and adolescent

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 Benefits of Attachment in
Adolescence
 Securely attached adolescents can:
 Reflective functioning
 Self reflect
 Perspective taking
 Express vulnerable emotions in a regulated manner
 Feel confident that they can express dissatisfaction with
parents or concerns in life without
 Fear of reprisal from parents
 Over burdening parents
 Fundamental trust that parents care about them and will
protect them

 Attachment is negotiated through conversation,

not behavioral control

Promoting Autonomy Topics

 Other factors contributing to the presenting problem
(e.g., depression and suicide ideation).

 Emerging maturity in the home

 Competency outside of the home
 Re-engage adolescents in social world/activities
 Self esteem is seen as a buffer against stress

 Identity Development
 Romantic relationships, sexuality, ethnicity, race, class,
religion, spirituality, etc.

 Is suicide still a coping mechanism for the adolescent?

Autonomy Promoting Task

 More client-centered
 Family generates important topics

 Usually occurs after all attachment ruptures are addressed

 May occur earlier if needed

 Majority of sessions should be family sessions, but some

individual sessions may be necessary

 Other family members are brought in if appropriate.

 Therapist mobilizes other mental health services if needed.
 Process: As sessions progress, therapist should need to do
less coaching.

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 Closing Statements
 Relationship building as the initial goal of treatment is
engaging for all family members.

 Helping clients access primary vulnerable emotions will

lead you to the heart of attachment needs and desires
and caregiver instincts.

 Don’t be afraid of suicide, conflict, emotion. The family

already is. This crisis can be an opportunity.

 You can have a structure, a theory, a model, and apply it

with great artistry.

 Trust yourself: work deeply sooner and move faster

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