Attachment and Family Therapy: Clinical Utility of ... Schwartz... · knowledge, new opportunities...

Attachment and Family Therapy: Clinical Utility ofAdolescent-Family Attachment Research*

HOWARD A. LIDDLE, Ed.D.†SETH J. SCHWARTZ, Ph.D.‡

The divide separating research and clin-ical work is narrowing. New therapies havebeen informed by research from specialtiessuch as developmental psychology and de-velopmental psychopathology. In this arti-cle, we attempt to illustrate the usefulness ofresearch on attachment relations for family-based therapy with adolescents. We examinethe clinical utility of adolescent attachmentresearch within the context of multidimen-sional family therapy, an empirically sup-ported treatment model that has incorpo-rated developmental research, includingbasic research on attachment, in its assess-ment and intervention framework.

Fam Proc 41:455–476, 2002

Up to now the family therapy movement hasdone better in the area of how-to-change-itthan of what-to-change. Descriptions of thecreature that family therapists are out to gethave been notoriously unsatisfactory. Clini-cians know that there is something rustlingabout in the bushes, but nobody has done agood job of finding it and explaining what itis.

—Lynn Hoffman (p. 176, 1981).Foundations of Family Therapy

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THE interface between clinical and de-velopmental processes has been a

subject of considerable interest within thescientific and treatment communities(Rutter, 1997). Developmental theory andresearch have informed clinical practice,and new treatments systematically targetdevelopmental processes (see Henggeler,Schoenwald, Borduin, et al., 1998; Liddle,2002). These therapies use knowledgeabout research-established risk and pro-tective factors to inform assessment andintervention. Although exemplars existabout how to use research findings in clin-ical theory, model development, and prac-tice (e.g., Liddle, Rowe, Dakof, & Lyke,1998; Liddle, Rowe, Diamond, et al.,2000), more of this translational workneeds to be done (Cicchetti & Toth, 1995;Shirk, Talmi, & Olds, 2000). As new find-ings emerge, and as specialties of re-search synthesize available empirical

* Preparation of this article was supported by Na-tional Institute on Drug Abuse grants P50DA11328-01 and T32 DA07297-06 (H. Liddle, Prin-cipal Investigator). We thank Gayle Dakof andCindy Rowe for their helpful comments on this arti-cle. Send correspondence to either author.

† Professor, Epidemiology & Public Health, Psy-chology, and Counseling Psychology and Director,Center for Treatment Research on Adolescent DrugAbuse, Send reprint requests to Howard A. Liddle,Ed.D., Center for Adolescent Drug Abuse, Depart-ment of Epidemiology and Public Health, Universityof Miami School of Medicine, Dominion Tower, Suite1108, 1400 N.W. 10th Avenue, Miami FL 33136;e-mail: [email protected]

‡ Research Assistant Professor. Center for FamilyStudies, Department of Psychiatry and BehavioralSciences, University of Miami School of Medicine,1425 N.W. 10th Avenue, 2nd Floor, Miami FL 33136;e-mail: [email protected]

455Family Process, Vol. 41, No. 3, 2002 © FPI, Inc.

knowledge, new opportunities to mine theclinical implications of this work materi-alize. In the current era of systematictherapy development and treatment ac-countability, an accurate and clinicallyuseful knowledge base about human de-velopment and dysfunction is more im-portant than ever before. This article fo-cuses on research findings in the area ofadolescent-family attachment. Clinical vi-gnettes and transcript material illustratehow research advances in this contentarea have been useful in our therapy de-velopment and research (Liddle, Dakof,Parker, et al., 2001; Liddle & Hogue,2001).

It is reasonable to expect that attach-ment research holds promise as a sourceof clinical influence. The empirically es-tablished connection of solid attachmentrelations to developmental outcomes iswidely known (Henry, Feehan, McGee, etal., 1993; Tarter, Vanyukov, Giancola, etal., 1999). Attachment offers a systemicconceptual framework about human de-velopment and dysfunction. Its traditionand content are in harmony with familytherapy’s sensibilities. For instance, at-tachment theory and research have re-spected, understood, and exploited theinterplay between individual and inter-personal/transactional functioning. Thetransgenerational perspective of attach-ment theory and research is another as-pect of attachment and family therapycompatibility (Doane, Hill, & Diamond,1991). Attachment theory and researchon the development-enhancing attach-ment relationships have been used to cre-ate prevention interventions for teenproblem behaviors. Studies conducted byAllen and colleagues, for instance, demon-strate how key aspects of attachmentcan serve as organizers for adolescentproblem prevention programs (Allen, Phil-liber, Herrling, & Kuperminc, 1997). Otherclinical applications of attachment re-search in clinical work are underway as

well (e.g., Johnson, Maddeaux, & Blouin,1998; Luthar & Cicchetti, 2000; Sexson,Glanville, & Kaslow, 2001). Finally, bydefinition and from its outset, attachmenthas focused on and elucidated the devel-opmentally informative and life-long in-fluencing parent-offspring relationshipsystem—a core emphasis of (and simi-larly, a “by definition” aspect of) familytherapy.

Attachment relations in the adolescentyears, and the second decade of life gen-erally, are particularly interesting. Ado-lescence is a time of transformation.Changes are required across many lifespheres. Family relations must changedramatically. For example, adolescentsneed to remain connected to their parentswhile at the same time increasing theirautonomy from their families and deepen-ing their connection to peers of both sexes.These changes are interdependent. Theyoccur in tandem. Autonomy does not de-velop in isolation; it grows in the contextof a changing but still close relationshipwith one’s parents. These processes con-stitute difficult balancing acts for non-clinical samples of teens and parents.When we consider teenagers and familymembers who are seen in clinics, thoseadolescents and their parents experienceserious and sometimes long-term inter-personal and familial stress, along withstress associated with negative events inextrafamilial systems such as schools, orwith legal matters. For these adolescentsand families, the developmental chal-lenges are enormous.

Broadly defined, attachment reflectsone’s degree of confidence that significantothers, usually family members, will pro-vide support and protection and will re-main within emotional proximity (Birin-gen, 1994; Bowlby, 1979). The quality ofthe family attachment system is largely afunction of the attachment relationshipsamong family members. This means thatmore organized, flexible, and cohesive

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families tend to be characterized by se-cure attachment among their members,while more distant and conflicted familiestend to be characterized by avoidant andinsecure attachment (Cobb, 1996). Secureattachment in adolescence is strongly re-lated to trusting and warm relationshipswith one’s parents (Tacon & Caldera,2001). Insecure adolescent attachment isassociated with ambivalence and distancebetween the adolescent and one or bothparents (Maio, Fincham, & Lycett, 2000).Parents’ attachment security matters a greatdeal as well. Mothers who were poorlyattached to their own parents as teenag-ers tend to have detached and chaotic re-lationships with their children (Newcomb& Loeb, 1999). Generally speaking, it isthe network of attachment relationshipswithin the family, more than any singlerelationship, that determines the overallhealth or dysfunction of the family envi-ronment (Sroufe, 1988).

In this article, we focus on the dismis-sive form of attachment, which is highlypredictive of a host of negative outcomes,including drug abuse, delinquency, andother forms of socially destructive behav-ior in adolescence and adulthood (see,Rosenstein & Horowitz, 1996). Dismissiveattachment signifies distance from andlack of concern for interpersonal relation-ships. One of its origins is poor goodness-of-fit between child temperament and pa-rental tolerance and personality (Bates,Pettit, Dodge, & Ridge, 1998).

Family therapy targets the family at-tachment system—the nexus of relation-ships within the family (Biringen, 1994;see Endnote 1, p. 472). Treatment shiftsthe family’s attachment system awayfrom dismissiveness and toward greatersecurity. This is accomplished by creatinga secure base within the family. Definedas a relational atmosphere that providesfamily members with access to safety andvalidation when needed, a secure base fa-cilitates both connectedness to the family

and exploration (e.g., social relationships)outside the family (Byng-Hall, 1999). Amongother things, family therapy targets observedinteractions among family members asone pathway to changing attachment re-lationships. Attachment relationships of-fer a framing device for interventions. Anattachment mind-set enhances a thera-pist’s overarching conceptual framework(i.e., assessment and corresponding inter-vention domains). A parent’s and adoles-cent’s attachment orientation is an impor-tant clue to their developmental level. At-tachment style determines how the teenand parent relate to the world and howeach derives meaning from external andrelational events (Best, Hauser, & Allen,1997). An attachment orientation pro-vides a ready-made, logical, easily under-standable frame within which one’s clini-cal work can be explained to families. Inone example, an attachment frameworkhas facilitated a therapeutic focus on thefamily’s relationship system rather thanon individual members’ shortcomings ormistakes (Johnson et al., 1998).

WHAT IS ATTACHMENT INADOLESCENCE?

Although attachment in adolescencebuilds on attachment in childhood, andattachment styles are likely to be stablefrom childhood to adolescence (Weinfield,Sroufe, & Egeland, 2000), attachment isdifferent in adolescence than in child-hood. Adolescents’ relational networks ex-pand well beyond the family’s bound-aries and into extrafamilial domains, andthis influences intrafamilial attachmentrelationships. Problems in school, for ex-ample, impact various spheres of develop-ment, including parent-child relation-ships.

Some parents are not aware that a de-crease in parental attention is normative.They may need to be reassured that a lessfrequent use of the parental safety net isdevelopmentally appropriate in adoles-

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cence (Steinberg & Silverberg, 1986). Forinstance, in one case the mother noted: “Itseems like he doesn’t need me any more.We used to have such a great relation-ship. But now he only comes to me everynow and then.” The therapist normalizedthe mother’s distress: “Adolescents wantand need to be independent. But they stillneed their parents. It’s just that you’reneeded in different ways now.” Therapyhas an educative component. Often, ther-apists can outline these new ways of re-lating for parents who have difficultymaking the adjustment to the adoles-cent’s and family’s new stage of develop-ment. Self-help books (e.g., Steinberg &Levine, 1996) can be very useful in com-municating accurate, research-informedinformation and guidance. Althoughchanges in parenting practices requiresmore than the provision of information(e.g., Schmidt, Liddle, & Dakof, 1996),bringing accurate knowledge and tailor-ing this knowledge into one’s changestrategies creates the kind of complex in-tervention approach that is more likely tohave success with clinical phenomenathat are themselves complex and multide-termined.

A teen’s progression into a more activeand autonomous role within the familyhas obvious treatment implications. First,therapists must regard the adolescent asa full participant in family treatment(Holmbeck & Updegrove, 1995). The ado-lescent’s point of view is instrumental totherapy’s launch and to its success. Facil-itating teen input into all aspects of thetherapy process is important. One charac-teristic of distant and conflicted familiesis a weak emotional bond between parentand adolescent. In these families, adoles-cents often feel that their feelings andopinions are unimportant (Allen, Moore,& Kuperminc, 1997). Concomitantly, par-ents tend to feel that they have little or noinfluence over their adolescents (Patter-son, Bank, & Stoolmiller, 1990). Under

these circumstances, of course, parent-ad-olescent communication is ineffective.Talk often focuses on squabbles abouttrivial events, and the poor relationshipbetween teen and parents tends to cyclenegatively with new, more difficult devel-opmental and relational challenges. Fam-ily interventions that achieve substantiveinput from both adolescent and parentenable a workable therapeutic system toform. It is from this platform that the realwork of therapy begins—the articulationand working of core relationship/thera-peutic themes (Liddle, 2002).

Autonomous Relatedness: As adoles-cents become more active participants intheir families, they also extend their net-work of significant relationships beyondthe family (Steinberg & Silverberg, 1986).As peers become more important, in-creased distancing between parents andoffspring is normative (Conger & Ge,1999). Therapists must help parents in-terpret these events as normal, indeedimportant new developments for theirteen. Parents who adjust their parentingstyles in response to their teens’ changesare more likely to have psychologicallyhealthy adolescents than parents who co-ercively attempt to constrain their adoles-cents’ extrafamilial involvements. Par-ents in this latter group place theiryoungsters at risk for academic problems,drug involvement, and delinquency (Gray& Steinberg, 1999). Adaptive adjustmentsin parenting include granting more au-tonomy, inviting the adolescent to partic-ipate in family decisions, and discussingparental monitoring issues in a moredemocratic way (Barrera, Castro, &Biglan, 1999). Although clearly there arecultural and contextual variations inthese adaptive accommodations (e.g., in-ner-city parents tend to modify their fam-ily management styles [particularly mon-itoring] to a lesser extent than do subur-ban parents), all families must alter their


parenting styles to some extent as theirchildren grow into adolescence.

This excerpt between a mother (Mo)and a therapist (Th) addresses the com-plexities of adaptation in families withchanging parent-teen relationships.

Mo: He’s my baby. I don’t want him togrow up. I want him to be mybaby.

Th: But he’s sixteen years old. Maybehe needs to talk to you and relateto you differently than he used to.

Mo: What do you mean? I’m still hismother, and he’s still my son.

Th: Of course, but things changeswhen kids become teenagers. Heneeds some more leeway from younow. He still needs you to bethere. He still needs your loveand support, that’s for sure, buthe’s ready to do more for himselfnow.

Mo: So it is possible for us to still havea good relationship, even thoughhe’s different than he used to be?

Th: Of course.

Contrary to the myths of adolescence,the youngster’s widening social radiusand desire for increasing autonomy do notpreclude strong family relationships.Most adolescents report feeling close totheir parents and wanting to maintainclose family ties (Ohannessian, Lerner,Lerner, & von Eye, 1998). Moreover, ado-lescent self-esteem, psychosocial compe-tence, peer acceptance, and school perfor-mance are associated with familial at-tachments (Allen, Moore, Kuperminc, &Bell, 1998).

What does change between childhoodand adolescence is the degree of emo-tional dependency on parents (Lieber-man, Doyle, & Markiewicz, 1999). As ad-olescents acquire the capacity for self-di-rection and independent thought, theirattachments to parents can becomesources of mutual support (Best, Hauser,

& Allen, 1997). Mutuality of support sig-nifies a bidirectional affective exchangebetween parents and adolescents, suchthat each party acknowledges and under-stands the other’s feelings and view-points. Whereas children serve mostly asrecipients of family support, in adoles-cence relationships between parents andteens become more reciprocal (Collins,1990). The changing relations in the fam-ily can cause stress, but they can also leadto adolescents and parents becoming sup-port sources for one another.

In dismissive families, mutually sup-portive relationships are unlikely to bepresent. Therefore, family therapy usesthe adolescent’s increasing intellectualand emotional capacities to create bidirec-tional relationships with parents. Thepresence of bidirectional and supportiverelationships is one aspect of the securebase. The next vignette includes a 17-year-old boy (Adol) and his estranged fa-ther (Fa), along with the therapist (Th). Itshows how treatment capitalizes on anadolescent’s ability to reciprocate paren-tal overtures and expressions of feeling.

Fa: Right now, me and you are juststarting to get back in tune, youknow what I mean? It’s not go-ing to happen overnight. First ofall, you’ve got to feel like youcan trust me to where you cancome to me with anything—Idon’t care how bad it maysound, I don’t care how negativeit may be.

Th: Because you’re there for him.Tell him that.

Fa: I want you to be able to say tome, “Dad, I need you.” And thenI look in your face and say,“Billy, I’m here for you. I’m nothere for you as your friend, asyour buddy. I’m here for you asyour father.” I hear what you’resaying. I feel your pain. I feel itright here [pats his chest]. I



want you to understand that I’mgoing to be there for you. That’swhy I’m going through these le-gal problems with you becauseyou’re my son, and I love you. Ican’t say that I’m going to bethere for you yesterday, becauseyesterday is already gone. Butwhat I can say is that I’m goingto be there today, tomorrow, thenext day, and the next day.That’s why you’re with me now.

Th: What do you think about whatyour dad said?

Adol: I trust him. I believe everythinghe says. I’m there for him too.I’m going to give him my wordtoo.

Th: You tell him then.

Adol: I say, if you’re going to be there,I’m going to be there too. I’mgoing to cooperate. Just like youlove me, I love you too. Ain’tnothing going to stop us fromyou being my daddy or from mebeing your son. Like you said,we can’t do nothing to help thepast, but we can do somethingto help the future.

The developmental push for self-direc-tion and autonomy is accomplished con-currently with changes in family rela-tions. Relationships in the family can be-come destabilized as adolescents extendtheir social networks beyond the family(Silverberg, 1996). Healthy family func-tioning, in the form of the secure base, isdependent on the balance of collaborationwithin the family and exploration outsidethe family (Allen & Hauser, 1996). Thisdynamic interplay—a dialectical pro-cess—between collaboration and explora-tion has been termed autonomous related-ness (Allen & Land, 1999). Autonomousrelatedness allows the adolescent to drawon (and provide) family support while stillpursuing extrafamilial involvements. Ifautonomous relatedness is established,

the adolescent begins to make significantcontributions to the family. When parentsnot only sanction autonomous relatednessin their adolescents but also display itthemselves, the teen is more likely to be-come a prosocial adult (e.g., employed, in-volved in stable interpersonal relation-ships; Allen & Hauser, 1996).

In the following clinical example, a 16-year-old male (Adol) confronts his moth-er’s desire to date:

Th: So, Michael, how do you feelabout your mom wanting tostart dating again?

Adol: I don’t like it. She’s my mom,and I should be her first prior-ity.

Mo: You are my first priority. I justwant a relationship in my lifenow so I don’t have to be aloneanymore.

Th: Michael, you don’t think it’s pos-sible for your mom to have aboyfriend and still be a goodmother for you?

Adol: I don’t know—I guess maybeshe could.

Th: Well, you have friends, don’tyou?

Adol: Yeah.

Th: Do you think it bothers yourmom that you don’t spend allyour time at home with her?

Adol: I guess not.

Mo: Well, it doesn’t.

Th: Then couldn’t it work the otherway around? Couldn’t yourmother have a boyfriend andstill be there for you?

Adol: She could, but that would be achange, a change for me.

Internalization of Disrupted Attach-ment as a Relational Characteristic: Dis-missive family attachment networks andadolescent attachment styles often resultfrom either attachment disruptions in the


family’s history (Kobak, 1999) or disrup-tions in initial attachment formation (i.e.,poor goodness-of-fit between parents andyoung children; Allen et al., 1997). Dis-ruptions in childhood attachment rela-tionships are likely to be internalized asrelational problems in adolescence (Thomp-son, 1999). Therapy addresses these rela-tional problems in terms of the adoles-cent’s primary relationships with familymembers, as a means of changing the teen’sand family’s relational style. Changes inrelational styles indicate that internal-ized attachment representations mayhave been modified, and thus the effectsof prior disruptions have been reduced(Rutter & Sroufe, 2000).

When attachment style becomes inter-nalized in adolescence, it becomes a per-sonality characteristic that generalizes torelationships outside the family (e.g., peerrelationships). Generalization of attach-ment style from family to peer relation-ships can be particularly problematic foradolescents who show an internalized dis-missive attachment style. For example,teens from conflicted and detached fami-lies may search for attachment security inpeer relationships (Lahey, Gordon, Loe-ber, et al., 1999). The peers to whom theyturn are often similarly detached fromtheir families (Burks, Dodge, Price, &Laird, 1999). Detachment from the familyand other positive social institutions isassociated with deviance and antisocialinvolvement (Rosenstein & Horowitz,1996), especially when adolescents havejoined socially detached peer groups. Thissegment illustrates how detachment fromfamily plays a role in antisocial affilia-tions:

Adol: I had a dad, but he was doinghis own thing, you know, so Iused to have no chance of goalachievement or stuff like that.So I started off wanting to be athug. I didn’t care what nobodytold me. I started smoking

weed, and then, the more Ismoked weed, the more itmessed my head up to get outthere and get more money.When I started smoking weed Iused to get greedy. I used to getmoney, I used to go up thestreet, and the boys—the bigtime drug dealers—they used toalways see me and come sit withme, and they’d give me moneywhen I’d get ready to leave.They used to be gamblers, sowhen I’d get the money fromthem, I’d go gamble. I used to bereal lucky—that’s how I got myname, because I would alwayshit the big craps hand. I used tothink I was bad or something.

Here is another example of a teen wholacks any type of healthy base for rela-tionships and autonomous, adaptive func-tioning because of severe inconsistencieswith caregivers.

Th: So here’s a little boy who’s sevenyears old, he doesn’t speak En-glish, he comes to this city fromPuerto Rico, he doesn’t knowwhat’s going on, he meets bothhis parents—never met ’em be-fore, lives in a bunch of differentneighborhoods, goes to live withstrangers. Boy, that was a lot.How easy do you think that wasfor you, as a little a little seven-year-old boy?

Adol: To me it was easier than itshould’a been, because I didn’treally know like the mother andfather routine. All I knew was, Iwas somewhere, and they said“Oh go here, oh go there.” Youknow what I’m saying, I didn’tgrow up with my mom, I didn’tget taught no lessons or nothin’.I see all these people livin’ nor-mal, and I’m like, man . . . what’sthat?

Th: What is the mother and fatherroutine? What is that?



Adol: You know, like you live, yougrow up with your mother andfather, and they teach you rightfrom wrong and the do’s anddon’ts. You know, I didn’t growup like that. They ain’t everteach me no right ’n wrong.

Changing the adolescent’s and family’sattachment orientation may require anexamination of the family’s recollectionsand feelings about their past history to-gether (Akister, 1998). Such examinationdraws upon the perspective taking andabstract thinking abilities that developduring adolescence. These advanced think-ing capacities have important clinical im-plications for repairing the attachmentnetwork in disconnected and conflictedfamilies. As adolescents develop abstractreasoning skills, they acquire a new senseof the ‘big picture’ (Chandler, 1987), in-cluding their role within the family andthe events that have precipitated theirown and their family’s current condition.Although children are generally not capa-ble of such an abstract analysis, adoles-cents’ increasing ability to engage inhigher levels of thinking provides an op-portunity to guide a critical exploration ofthe past with the entire family.

In examining a family’s past, it is crit-ical that the therapist help the family tocreate a coherent story about what hap-pened and how the family’s attachmentsystem may have been disrupted (Byng-Hall, 1995). Past events should be re-framed so as to focus on the family’s at-tachment system rather than on individ-uals’ faults or mistakes (Akister, 1998).The therapist emphasizes that exploringthe past is not about blame. Formulatingthe secure base involves making sense ofthe past and of the feelings associatedwith it, so that all members’ feelings andviews about the past are voiced and un-derstood. Parental substance abuse, hos-pitalization or incarceration, or healthproblems (Nurco, Blatchley, Hanlon, &

O’Grady, 1999) are common in clinicalsamples of teens, and these are examplesof events that may have shaped currentevents in powerful ways. Connecting thepresent with the past is an important as-pect of clinical work with detached fami-lies (Diamond & Liddle, 1999).

Facilitating a certain accepting andnonjudgmental tone is key, but content isimportant as well. Trivial chitchat willnot heal broken relational bonds. Opencommunication and the facilitation of amutual and genuine responsiveness areinstrumental to healing damaged rela-tionships (Best et al., 1997; Fonagy, Tar-get, Steele, et al., 1997; Kobak, 1999).Harsh parental confrontations and chal-lenges can exacerbate existing conflictand resentment (Barrera et al., 1999;Rodgers, 1998). Through targeted inter-ventions, adolescents and parents arehelped to believe that it is safe to trustone another, in spite of past disappoint-ments, conflicts, and betrayals. Teenswho can discuss and conceptualize attach-ment experiences and relationships inways that reflect balance, understanding,autonomy, and acknowledgment of thesignificance of attachment (Allen et al.,1998) have more favorable developmentaloutcomes across multiple domains thanadolescents who do not develop this ca-pacity.

The following vignette addresses ateen’s understanding of his mother’s prioralcoholism and concomitant unavailabil-ity:

Th: [to Mo] You were having a roughtime at one point.

Mo: That’s when I was drinking, andyou [son] would never under-stand that. I didn’t just drinkfor drinking. The only time Iwould drink was when some ofthat old stuff from when I was achild came up.


Th: It’s important for him to under-stand that. But there’s anotherissue about how your drinkingproblem affected both of you.You lost some time as motherand son, because when you’reusing or drinking, you’re not al-ways so ‘with it’. Does he under-stand all that now?

Mo: I don’t think so.

Th: [to adolescent] Do you knowthat your mom had a reallyhard life, Michael?

Adol: No, not really.

Mo: My mother died when I was hisage, and we had to fend for our-selves. It was hard. When mymother passed away, my fatherwalked out.

Th: [to adol] Did you know all this?

Adol: I’ve heard about it.

Mo: Every time I would think of allthis, I used to drink. [to son] I’mtalking to you too.

Adol: I remember. I used to wait foryou at the bus stop in the morn-ing after you’d been out all nightpartying. I used to be so happywhen I’d see you get off thatbus.

Mo: Well all that’s over. I’m backnow.

Understanding the past from every-one’s perspective is a necessary step increating the secure base (Byng-Hall,1991). Feelings of blame, hurt, mistrust,and disappointment detour individualand relationship development (Shaw,Bell, & Gilliom, 2000). In order for theadolescent and parent to develop a devel-opmental stage appropriate connection,these negative feelings underlying thedistance in their relationship are ad-dressed in treatment. Rumination, self-recrimination and/or blame are naturaland common elements in this process. Atthe same time, if these themes are too

plentiful and do not transform into morepresent and “what can we do now?” dis-cussions, therapy can, as Haley (1976)warned some time ago, become nonpro-ductive. Forgiveness and acceptance areimportant parts of the process of changingattachment relationships.

Externalizing problems provide a fer-tile ground on which to demonstrate theclinical relevance of attachment research.Externalizing problems are generally as-sociated with dismissive attachment andwith a history of disruptions in the familyattachment system (Clark, Lesnick, &Hegedus, 1997). The effects of these dis-ruptions illustrate how attachment prob-lems have familial and intrapersonal andindividual aspects. As an example, mari-tal problems between parents are predic-tive of compromised parent-adolescent at-tachment relationships (Allen, Hauser,O’Connor, et al., 1996). Any disruptionwithin the family attachment system im-pairs the family’s ability to provide a se-cure base.

Dismissive attachment reflects the ab-sence of a coherent attachment system tofacilitate normative and necessary familyreorganizations associated with adoles-cence. The transition to adolescencestretches the family’s limits and strainsits attachment system (Kidwell, Fischer,Dunham, & Baranowski, 1983). Even se-curely attached families experience no-ticeable parent-child distancing duringearly adolescence. Dismissive families,whose relationship systems are fragileand distant to begin with, can be severelycompromised by a child’s passage into ad-olescence (Allen & Land, 1999). The ado-lescent’s push for autonomy, if not bal-anced by relatedness, can lead to familydisruption and to drug abuse and delin-quency (Silverberg & Gondoli, 1996). Par-ents not positively attached to their ado-lescents may implement power-assertiveand adversarial disciplinary techniquesintended to curtail antisocial adolescent



behavior (Dishion & Patterson, 1997).However, the result of these actions maybe the opposite of what was planned, driv-ing the adolescent farther away from theparent and toward like-minded (i.e., an-gry or oppositional) peers (Maccoby,1992). In the face of such perceived pow-erlessness, particularly when the parenthas made several unsuccessful attemptsto reach out to the adolescent, parentsbecome frustrated and feel ready to giveup. However, just as teens who starttreatment with a negative set and poortherapeutic alliance can change and be-come engaged in therapy (Diamond,Liddle, Hogue, & Dakof, 1999), parentswho begin treatment with a pessimisticmind set and deleterious parenting prac-tices can change as well (Schmidt et al.,1996). In these domains of therapy andchange, research-derived knowledge aboutdevelopment and dysfunction is integratedinto the therapeutic system which is in-formed by the ecological perspective andpremises about change (Liddle, 1999).

THERAPEUTIC INTERVENTION FORDISMISSIVE ATTACHMENT

Attachment to Therapist

Clinical research has found that pro-ductive family discussions are unlikely tooccur until both the parents and the ado-lescent have come to trust the clinicianand to believe that they can benefit fromtreatment (see Diamond et al., 1999). Inattachment terms, family members mustbecome securely attached to the therapist(Akister, 1998). It is helpful if both theparents and the adolescent feel that theclinician cares about them, is invested intheir development, and seems willing toput forth the necessary effort to bringabout meaningful and lasting change(Lindegger & Barry, 1999). A separateworking alliance is established with eachfamily member.

In our clinical model, MultidimensionalFamily Therapy (MDFT; Liddle, 2002;Liddle, Dakof, & Diamond, 1991), treat-ment’s initial phase establishes severalworking alliances inside and outside thefamily simultaneously. To build a rela-tionship with the adolescent, MDFT usesAdolescent Engagement Interventions(AEI), which communicate basic attach-ment-related messages to teens, includ-ing that (a) there is something for them togain from therapy, (b) they have a right tofeel as they do, (c) the relational goalsthat they develop (e.g., being able to telltheir parents how they feel) can be accom-plished during the course of treatment,and (d) their participation is instrumentalto treatment’s success. These messagesall reflect secure attachment relation-ships, in the form of genuine interest, val-idation, desire for partnership, and ac-knowledgment of the adolescent’s crucialrole in the therapeutic process. The char-acteristics of secure attachment relationsare related to all of the messages commu-nicated in the AEI, including trust,warmth, caring and commitment accep-tance, validation of feelings, interest inthe adolescent’s goals, and encouragingthe adolescent to participate fully in therelationship (Allen & Hauser, 1996; Allen& Land, 1999; Woodward, Fergusson, &Belsky, 2000).

Th: I’m going to prove to you thatI’m trustworthy, okay? I think Ican do that. My hope is thatwhen I do that with you, youwill say: “Okay, I can deal withsome of my issues here.” Do youknow what I mean?

Adol: It means I can talk about what’sbothering me.

Engaging parents into treatment is ac-complished through Parental Reconnec-tion Interventions (PRI). The PRI, a mod-ule based on research (as is the AEI),structures therapy—provides a generic


therapeutic objective (something impor-tant to do with every case) and a corre-sponding set of behaviors to facilitate theobjective’s achievement. Parents in dis-missive and conflicted families are frus-trated by their inability to communicatewith or control their adolescents, and insome cases they are giving up entirely(Brown, 1993; Liddle, Rowe, et al., 1998).Therefore, reestablishing parental feel-ings of love toward, commitment to, andinfluence over their adolescents is essen-tial in securing parents’ active participa-tion in therapy. These positive parentalattitudes and behaviors have all beenfound to reflect secure adolescent-parentattachment (Allen, Hauser, & Borman-Spurrell, 1996; Tacon & Caldera, 2001).

The PRI aims to facilitate parental feel-ings that are associated with secure at-tachment and protect against problem be-haviors. Such protective parental feelingsinclude warmth, investment, closeness,and concern (Dekovic, 1999; Palmer &Hollin, 2001). Fostering these feelings caninvolve challenging the parent’s disen-gagement, abdication, and readiness togive up.2

Engaging parents into treatment in-volves more than rekindling love andcommitment toward the adolescent, how-ever. Parents often spend significantamounts of in-session time discussingtheir own families of origin and other per-sonal topics independent of the adolescent(Doane & Diamond, 1994). Research hasshown that quality of parenting is signif-icantly affected by the parent’s nonpa-renting adult life (e.g., Silverberg, 1996).For this reason, in addition to targetinghis or her role vis-a-vis the adolescent, wefocus on the parent as a separate personwith his or her own life and issues (Liddleet al., 1991). Establishing a secure attach-ment relationship with parents involvesassuring them that their own concernsand feelings can be addressed in treat-ment. Increasing the degree of stability

and positive affect in a parent’s life mayimprove that parent’s interactions withhis or her adolescent (Newcomb & Loeb,1999). Furthermore, demonstrating to theparent that the therapist cares about heras a person, not just as a parent, canfacilitate a secure parent-therapist rela-tionship (Becker & Liddle, 2001). In thecase example presented here, the motheris feeling lonely and overwhelmed. Thereconnection process begins by helpingthis mother to feel connected and sup-ported so that she can focus on helpingher son.

Mo: I just feel so lonely and de-pressed. It’s not just Jason, it’severything. I feel like my life isfalling apart.

Th: We can deal with that here. Thisis about Jason but it’s about thewhole family too.

Mo: Really? You can help me too?

Th: Yes. We do family counselinghere, and that means helping ev-eryone, including you.

Encouraging Autonomous Relatedness:In the context of a developing set of con-nections between the therapist and theparent and the therapist and adolescent,the therapist uses these relationshipsstrategically to facilitate change. Individ-ual sessions with adolescent and parentare mingled with joint sessions to facili-tate communication and connection, andto titrate and try to transform unproduc-tive conflict. That is, the therapist can usethe attachment security established sep-arately with each family member to cre-ate a new relationship between parentand adolescent. As this communicationprogresses, the security of attachmentcan transfer from the therapist to thefamily itself (Byng-Hall, 1999).

In the following example, the therapistacts as a mediator between David, a 16-year-old adolescent referred to treatmentfor cocaine abuse, and his parents. The



therapist knows that the family is discon-nected and conflict-ridden. He interpretsthe adolescent’s statements and reframesthem for the parents, and vice versa. Al-though the feelings discussed are mostlynegative in nature, the therapist is suc-cessful in facilitating some degree of me-diated conversation between David andhis parents.

Th: Your father wants to talk abouthow to have a relationship withyou where there is trust. Pastevents have eroded the trust.

Adol: I understood what he was say-ing, but I’m damned if I do, andI’m damned if I don’t.

Th: [to parents] Maybe each of youcan talk about what the big pic-ture is for you. Why is it so dif-ficult to recapture a big picturethat has the two of you beingtogether?

Fa: David doesn’t even understandwhat the issue is. I think thebottom line is that Daviddoesn’t understand why he’s nottrusted.

Th: [to adolescent] What sort of re-lationship do you want withyour parents now?

Adol: They want it to get closer, and Iwant it to get further apart.

Th: Explain to them why you feelthat way?

Adol: I just don’t feel like I can trustthem.

Building a secure family attachmentsystem involves facilitating autonomousrelatedness within the family (cf. Allen,Hauser, Bell, & O’Connor, 1994). Fami-lies with dismissive interactional processstyles have been characterized as havingan oversupply of independence and insuf-ficient relatedness (Allen, Hauser, & Bor-man-Spurrell, 1996). Facilitating commu-nication among family members, whilecontinuing to support each person’s au-

tonomy (e.g., gently reminding the par-ents that the adolescent is increasinglycapable of participating in family decisions,and encouraging them to talk to the ado-lescent about their nonparenting adultlives) promotes movement toward auton-omous relatedness. Helping families toprocess negative emotions, and usingthem to craft guiding themes for thera-peutic work, is one way in which we facil-itate closeness and relatedness (Liddle,1994). In some conflicted and distant fam-ilies, adolescents express a desire to “payback” their parents for past abuse or ne-glect (Liddle et al., 1991). Themes of ado-lescent forgiveness and parental account-ability can be used to draw the parent andadolescent closer together. Alliance build-ing and therapist-facilitated attachmentsecurity create a safe environment inwhich the parent may feel free to explainto the adolescent, in an apologetic way,why he was emotionally or physically un-available in the past. The adolescent, inturn, is provided an open environment inwhich to address his disappointment andanger toward the parent. Obviously, caremust be taken to help the expression ofthese experiences in constructive ways.The honest and emotional atmospherethat results may help to establish con-nectedness while respecting each party’sviewpoint (cf. Tacon & Caldera, 2001).

The following case illustrates theseprinciples. The adolescent, Marvin, hasbeen court-ordered to treatment and tolive with his father. Father and son havehad no contact in many years. The thera-pist develops the theme of reconciliationand forgiveness to encourage both fatherand son to be open and forgiving and tobegin forming a new relationship.

Th: I’ve been thinking about thethings that you said. What Ihear is that “if I had been therefor him when he was younger,he wouldn’t be in this muchtrouble.” Some people might


look at your insight on this as aburden, but others might see itas a gift (which is the side I seeyou getting at). My question isthis: What are you going to dowith this insight? Can you use itto help yourself and your son?

Fa: To give myself the piece of mind,I will do my best to reverse theimpression, you know. I stillwant him to grow up, and I stillwant him to be his own man,but at the same time, I have toinstill in him what I’ve alwayswanted for him. I want to donow what I should have donefive, six, seven, eight years ago.You know, I want to be able tosit him down and be able to sayto him, “Look, this is your life. Ilove you, you’re my son, but thisis your life. I can’t make yourdecisions for you.”

Th: This is really good that you saythat. This is the kind of thingI’m going to help you with, withMarvin. It’s going to take time.It’s going to be hard sometimes,and you might get mad at mesometimes, because I’m going toask both of you to do thingsyou’re not used to. I’m going toask you both to talk to eachother in a new way. You are theone who’s going to be able to in-fluence him. And it’s going tostart with you listening to himand your son listening to whatyou just said. Do you under-stand?

Fa: Oh, yeah.

[Th. brings adol. into the room]

Fa: Your dad has something to askyou.

[Adol. laughs nervously but says nothing.]

Th: [to Fa] This is hard for your son.

Fa: He ain’t been able to talk to mefor years. He knows that I knowthat I haven’t been there for

him like I should. He hasn’tbeen able to really talk to melike he wants to, because Ihaven’t been there. It’s just likewe’re starting over again. Theonly thing is, it’s not me talkingto a little kid any more. It’s metalking to a young man, soon tobe a young adult. I want him tounderstand that I don’t haveanything against him for thetrouble that he’s gotten into. Idon’t like it, but just like I wastelling her [therapist], a lot ofthe things that you’ve gotteninto, I partially fault myself forthat.

Th: Marvin, what do you thinkabout what your dad is saying? Iknow you have things you wantto tell him, so what do you thinkabout what he’s saying? He’ssaying a lot of good things. I knowthis is new for both of you, to sitand talk to each other like this,but I know you’ve got a lot to say.

Fa: Speak your mind. Tell me whatyou feel.

[Adol. smiles nervously, rolls his headaround in a circle]

Th: What do you want to say to yourdad?

Fa: Start with whatever you feel.I’m not going to get mad withyou because you say something[I don’t like]. I want to find outwhat I need to do to make itbetter for you.

Th: And he also said that he wantsto understand what you wentthrough. By understanding whatyou went through, he’s going tounderstand you better, and youare going to understand him bet-ter by listening to what he justsaid.

[Adol. laughs nervously]

Th: Tell your dad the main thingsyou want him to know.



Adol: The main thing I’d say is thatit’s probably been a father andson thing.

Th: You mean you wanted a rela-tionship with your dad?

Adol: Yeah, because the kids, they’llbe joking around, and they’lljust start in on me. They’ll say,“That’s why you ain’t got nodaddy or nothing.” I used to getso mad I had to leave and gosomewhere else.

Th: Their teasing made you mad?

Adol: Yeah! I used to be mad, so I’dleave, and I’d just go chill in thepark for a couple of hours, andI’d just think about it. I’d say,“Man, I don’t know why thathappened to me.” And I’d say, “Idon’t even know where mydaddy is at right now.” I used tothink, “I don’t even got nodaddy. I don’t know where mydaddy’s at. If I died right now,he probably wouldn’t even knowuntil somebody else told him.”

The father is encouraged to create asafe environment for his son’s expression.The father is supported for assuming re-sponsibility about being absent from hisson’s life. Within the secure atmospherethat has been created by both the thera-pist and father, the adolescent is helpedto reveal his thoughts and feelings. Thesesmall steps are instrumental, early-stagemovements in rebuilding the father-sonrelationship.

Changing Internalized Attachment Repre-sentations: MDFT attempts to re-weavethe fabric of parent-adolescent attach-ment. A hallmark of the dismissive andconflicted family is negative emotion thatquickly escalates out of control (Dishion &Patterson, 1997; Liddle, 1994). Persistentnegativity is associated with a weak par-ent-adolescent attachment bond (Allen,Hauser, O’Connor, et al., 1996). In manycases, negative emotion is related to

trauma and its long-term sequelae. Infamilies with traumatic histories, chronicnegativity can hide hurts and disappoint-ments and cement emotional distance(Doane & Diamond, 1994). For instance, ateenager whose father abandoned himemotionally or physically is understand-ably reluctant and possibly afraid to em-brace the father in the present, and maypush him away with hostility and aggres-sion. Until the fears and hurts have beendiscussed, chronic negativity will likelycontinue to impede therapeutic progress(Lindegger & Barry, 1999). Even whenthe therapist tries to intervene, parentsand adolescents may still return to thesubject of heated disagreement.

Mo: Take off those glasses until wefinish talking.

Adol: I don’t want to.

Mo: Take off those glasses. Takethose glasses off until we’re fin-ished!

Adol: I want to leave them on.

Mo: Take those glasses off! It’s notappropriate—don’t do that!Take ’em off or I’ll get up andtake ’em off!

Adol: I had ’em on before!

Mo: Ain’t no respect. Take thoseglasses off! [Gets up and at-tempts to pull the glasses off theadolescent’s face]

Adol: I don’t like the light in here.

Mo: [raising her voice]: Take ’em off!They’re disrespectful. [to thera-pist] They’re disrespectful toyou, right?

Th: That bothers you.

Mo: Yeah, it bothers me!

Adol: I bought the glasses myself!They ain’t bothering her!

Mo: Will you take those glasses off?

Ther: You’re saying it bothers you.

Mo: I’m saying it’s disrespectful!


When you talk to somebody,you’re supposed to talk to themthrough their eyes.

Adol: It ain’t being disrespectful. Idon’t like the light in here.

Th: This is the kind of thing thathappens at home, right? Youwould like him to do this thing,and the two of you get into itback and forth. Then do you giveup, or what?

Mo: It just don’t look right.

Adol: It just don’t look right to her.

Th: So there are some things—youhave your own style of dress.

Adol: Yeah. If she would have boughtit, I’d be happy to take it off.

Th: So I think there are some biggerissues, and there are somesmaller ones, and I think thereare some things you have morecontrol over than others, like hisclothes.

Mo: But his clothes—I’ve gotten tothe point where I don’t carewhat he wears. He wears whathe wants to wear, ’cause hedon’t go out nowhere with me.So he don’t have to wear noth-ing at all if he’s not going to bearound me with it.

Th: Because you don’t like what hewears.

Mo: No I don’t, and I’m not going topretend.

In an MDFT process study we referredto this pattern of spiraling negativity asthe therapeutic impasse (Diamond &Liddle, 1999). In-session impasses oftencentered on current behavioral concernssuch as household chores, parental super-vision, and peer associations. If joint ar-guments over these sorts of issues were tobegin, they could dominate the session.If the impasse was not addressed andresolved, the session would break downand therapeutic progress would stop, as it

did in the above example. Successful im-passe resolution was achieved by a shiftintervention. The shift intervention in-volved three therapist-initiated changesin response to the negativity. First, thefocus of conversation is changed from abehavioral to an emotional realm. Al-though it has cognitive and behavioral as-pects, attachment is closely intertwinedwith emotion, such that secure attach-ment is unlikely in the absence of warmthand closeness (Maio et al., 2000). The neg-ative feelings underlying the impasseneed to be exposed and examined beforethe family’s attachment system can be-come more secure. Helping parents andadolescents understand each person’s ex-perience of the other, particularly interms of relationship problems, is the firststep toward healing the relationshiphurts, reframing the family’s relationshiphistory, and developing a practical, devel-opmentally appropriate plan to moveahead in positive ways, despite all thathas come before. The following excerptprovides an example:

Th: So it’s not so much about whatMom did, but you got disap-pointed a lot, and sometimesnow, when you get disap-pointed, you think about thosethings. I’m not saying you’re notangry about it, and I think thatis sitting there between you andyour mom. But when it comesout, it’s difficult for your mom tohear you saying, “You did this,you did that.” Doesn’t it go bet-ter when you say, “Look, I waslet down sometimes; back then Ididn’t trust you?

Adol: It does.

Second, the focus of conversation ischanged temporarily from the present tothe past. Since negative family emotionalstates are associated with a history of con-flict and traumatic events (Allen &Hauser, 1996), part of impasse resolution



involves bringing the history of the prob-lem up for discussion. The following caseexample exemplifies the shift frompresent to past. Sixteen-year old Rita andher mother have been arguing about thefact that Rita is not working and has notbeen looking for a job. The therapistseizes an opportunity, in the form of astatement made by the mother, to explorewhy Rita is unwilling to seek help.

Th: Your mom wants you to get ajob. I know it’s hard—youhaven’t gotten a job before.

Mo: You can ask for help. [to thera-pist] Rita doesn’t ask for helpwith anything.

Th: Is there anything in the past,between the two of you, thatwould keep Rita from asking forhelp?

Adol: Yeah, there is.

Th: Tell me about it.

Adol: When I was younger, I used toask for help, and no one wouldhelp me.

Th: So you figure it’s pointless.You’re not going to get the help,so why bother asking?

Adol: A lot of things that I do are con-nected with things that hap-pened in the past.

Th: What do you mean?

Adol: I’m just scared I’m not going tobe helped. Maybe I just need tobe trusted for once. And I needto be loved, for once.

Th: What Rita said was powerful.She wants to be trusted. Weshould talk about that.

Mo: I agree. It was powerful.

Th: Can you respond to Rita?

Mo: I do love you, Rita. I’m sorry Ihaven’t been able to show youthat like I should. I’ve just beenunder a lot of stress lately. But Ialways want you to know that I

love you, and I will work on thetrust thing.

Adol: Okay, and I promise to get a joband start helping you trust me.If you’re going to be a bettermother, then I’m going to be abetter daughter.

Formation of a secure base is facilitatedif parents and adolescents understandeach other’s perceptions of what hap-pened. This is a shared task in whichparents and adolescents, along with thetherapist, collaborate in formulating amutual account of the family’s history.This history details the attachment dis-ruptions that occurred in the past, fromeveryone’s point of view, and how thosedisruptions have contributed to the cur-rent situation. Through arriving at ashared understanding of past events andhow they have shaped the family’s his-tory, parents and adolescents learn to livetogether in new ways. Empathy and ac-ceptance are important ingredients inthis process.

Third, the focus is shifted from aggres-sive emotions (e.g., anger and hostility) toan inquiry and sharing about other as-pects of the relationship experiences—as-pects that involve vulnerable and “soft”emotions (e.g., disappointment, regret,and abandonment). Research indicatesthat attachment problems are morestrongly related to tender emotions thanto aggressive ones (Dekovic, 1999; Palmer& Hollin, 2001). Therefore, addressing at-tachment problems is accomplished by at-tending to feelings of hurt, fear, and dis-illusionment. Dominant emotions such asaggression and rage are more distally as-sociated with attachment problems, andthey obscure other, more vulnerable feel-ings. Family members are supported intheir joint expression and exploration ofthe events and experiences that have ledto their current estrangement.


Th: [to Fa] Dad, what do you feelabout what your son just said?

Fa: That was deep. It’s hard to putinto words what I’m feeling rightnow. I know in my heart that a lotof things you’ve gotten into werebecause of me. Not because I didthis or I didn’t do that, but mainlybecause I wasn’t there for youwhen I should have been. I don’tfault you. You’ve done the thingsthat you felt—you got this big bar-rier up in front of you, and youdon’t want nobody to knock thatbarrier down, you’ve put up thisbig wall. And then you’re like,“Damn, where’s my daddy at? Mydaddy ain’t there.” I know whatyou’re going through because Iwent through the same thing withmy dad. I didn’t even know whomy father was. The only way Iknew who my father was was byhow many kids he had, how manywomen he had, and how much of aplayer he was. That was the onlything I could tell you about yourgranddaddy.

Th: So you know how your son feels.

Fa: Yeah. Believe me, I know how hefeels. It’s like a tape recorder—Icould have sat down thirty yearsago, and the same thing my son istelling me, I could have sat downand told my father. Because Iknow what he’s feeling—he’s feel-ing betrayed, he’s hurt, becausethere was a time when I was [stiff-ing] him. One minute I was there,and the next minute, “Where’s heat?” As your father, that’s myfault. I know what you feel, and Irespect what you feel. I can’tchange what I should have done, Ican’t change what I could havedone, I can’t change what I didn’tdo. All I can do is to try to makethings better for you from thispoint on, in any way that I possi-bly can. I know you’ve beenthrough a lot, and I know that a

lot of what you’re going through isbecause of me. The main thing is,I haven’t been there to listen toyou. But the only thing I can tellyou, son, is I love you, and I’ll bethere for you.

One of our MDFT process studiesteased apart this kind of in-session event.We determined the interactional charac-teristics, including therapist behaviors,that were associated with impasse resolu-tion. Compared to cases of unsuccessfulin-session impasse resolution, cases ofsuccessful resolution were characterizedby significantly less parental power asser-tiveness and greater levels of openness,collaborative negotiation, and assumptionof responsibility (Diamond & Liddle,1999). When the shift intervention wassuccessful, parents and adolescents, ini-tially engaged in intense conflict, werenow working together, respecting one an-other, open to suggestions from one an-other and from the therapist, and willingto claim responsibility for their respectiveroles in creating the impasse. In attach-ment terms, the parents and adolescentswere displaying autonomous relatednessand were behaving in ways characteristicof securely attached families (cf. Allen &Hauser, 1996). Warmth, trust, and con-cern between parents and adolescents, allsignificant correlates of attachment secu-rity (Allen et al., 1998), were increasinglypresent in families who had successfullynavigated the impasse.

In summary, MDFT addresses attach-ment problems in three ways. First, spe-cialized engagement and alliance buildingstrategies help both teenagers and par-ents to become securely attached to thetherapist so that they are in position toplay significant roles in the treatmentprocess. Second, particular techniquesand an overarching therapeutic protocolhelp to build attachment relationships be-tween physically or emotionally estrangedparents and adolescents, such that dis-



connection can be transformed into au-tonomous relatedness. Finally, shift in-terventions are used to access the “softer,”and at first, inaccessible feelings associ-ated with parent-adolescent conflict anddisconnection. The intervention facili-tates a new process between parent andteen, one aim of which is to help themformulate a shared and coherent storyabout the past (part of the process of cre-ating a platform from which participantsencounter a new relationship future).Taken together, these strategies are partof a treatment protocol that aims to repairdamaged attachment relationships andpromote the development of a secure fam-ily base.

SUMMARY AND CONCLUSION

We sought to illustrate the clinical rel-evance of attachment research for treat-ing families with adolescents. The attach-ment research literature was used toidentify some ways in which parent-ado-lescent distance and conflict can beframed as attachment problems. We dis-cussed the clinical implications of attach-ment research and discussed them withinmultidimensional family therapy, an es-tablished treatment designed to incorpo-rate developmental research findings. Weillustrated specific MDFT interventions,targeting each of the three adolescent at-tachment dimensions that we discussed.Finally, we presented empirical and clin-ical evidence that these interventions tar-get attachment processes associated witha secure family base.

The ability of developmental psychol-ogy and developmental psychopathologyto inform clinical practice relies on thera-pists’ knowledge of normative and non-normative processes in adolescence. Spe-cifically, if therapists understand how at-tachment relationships unravel or stayhealthy, their interventions can targetspecific mechanisms linked to positiveand negative developmental outcomes.

The furor in the field about the non-inter-action of research and practice has sub-sided. One sign of progress on this fronthas been in the realm addressed in thisarticle—changes in clinical practice broughtabout by the incorporation of knowledgeabout normative and nonnormative devel-opmental transitions. Substantive prog-ress since Hoffman’s challenge (see epi-graph of this article) is well underway.

ENDNOTES1 In Multidimensional Family Therapy,

attachment relations within the fam-ily are targeted as are relations be-tween family members and other so-cial institutions that have develop-mental influence (Liddle, 2002). Aparent’s and or adolescent’s relation-ships with school or juvenile justicesystems are routinely assessed andtargeted for change. This article fo-cuses mostly on intrafamilial attach-ment relations.

2 Adolescent Engagement Interventions(AEI) and Parental Reconnection In-terventions (PRI) are vital parts ofMDFT. This approach has definedkey therapeutic operations and estab-lished them at the level of therapeu-tic module—protocols are written forhow to engage in each aspect ofwork. The AEI and PRI are done si-multaneously, and they are begun inthe first stage of therapy. Both ofthese modules begin by working withthe teen (AEI) and parent (PRI)alone. Although composition of thesession for each of these modules isimportant, it is the therapeutic goals(beginning the process of reconnect-ing the parent and teen in a develop-mentally appropriate relationship, forexample) that drives the therapeuticoperations and decisions about ses-sion composition. Work within theAEI and PRI modules are intercon-nected. Work in one subsystem do-


main is used to shore up, create newopportunities, and potentiate clinicalfocus and work in other subsystems(see Liddle, 1995). In this regard,grandparents and siblings, as thetherapeutic focus, specifics, and goalsof the case dictate, are routinely in-cluded in the second stage of AEIand PRI interventions.

REFERENCESAkister, J. (1998). Attachment theory and sys-

temic practice: Research update. Journal ofFamily Therapy 20: 353–366.

Allen, J.P., & Hauser, S.T. (1996). Autonomyand relatedness in adolescent-family inter-actions as predictors of young adults’ statesof mind regarding attachment. Developmentand Psychopathology 8: 793–809.

Allen, J.P., Hauser, S.T., Bell, K.L., &O’Connor, T.G. (1994). Longitudinal assess-ment of autonomy and relatedness in ado-lescent-family interactions as predictors ofadolescent ego development and self-es-teem. Child Development 65: 179–194.

Allen, J.P., Hauser, S.T., & Borman-Spurrell,E. (1996). Attachment theory as a frame-work for understanding sequelae of severeadolescent psychopathology: An 11-year fol-low-up study. Journal of Consulting andClinical Psychology 64: 254–263.

Allen, J.P., Hauser, S.T., O’Connor, T.G., Bell,K.L., & Eickholt, C. (1996). The connectionof observed family conflict to adolescents’developing autonomous relatedness withparents. Development and Psychopathology8: 425–442.

Allen, J.P., & Land, D. (1999). Attachment inadolescence (pp. 319–335). In J. Cassidy &P.R. Shaver (eds.), Handbook of attachment:Theory, research, and clinical applications.New York: Guilford Press.

Allen, J.P., Moore, C.M., & Kuperminc, G.P.(1997). Developmental approaches to under-standing adolescent deviance (pp. 548–567).In S.S. Luthar, J.A. Burack, D. Cicchetti, &J.R. Weisz (eds.), Developmental psychopa-thology: Perspectives on adjustment, risk,and disorder. Cambridge, UK: CambridgeUniversity Press.

Allen, J.P., Moore, C., Kuperminc, G., & Bell,

K. (1998). Attachment and adolescent psy-chosocial functioning. Child Development69: 1406–1419.

Allen, J.P., Philliber, S., Herrling, S., & Ku-perminc, G.P. (1997). Preventing teen preg-nancy and academic failure: Experimentalevaluation of a developmentally based ap-proach. Child Development 64: 729–742.

Barrera, M., Jr., Castro, F.G., & Biglan, A.(1999). Ethnicity, substance use, and devel-opment: Exemplars for exploring group dif-ferences and similarities. Development andPsychopathology 11: 805–822.

Bates, J.E., Pettit, G.S., Dodge, K.A., & Ridge,B. (1998). Interaction of temperamental re-sistance to control and restrictive parentingin the development of externalizing behav-ior. Developmental Psychology 34: 982–995.

Becker, D., & Liddle, H.A. (2001). Family ther-apy with unmarried African Americanmothers and their adolescents. Family Pro-cess 40: 413–427.

Best, K.M., Hauser, S.T., & Allen, J.P. (1997).Predicting young adult competencies: Ado-lescent era parent and individual influences.Journal of Adolescent Research 12: 90–112.

Biringen, Z. (1994). Attachment theory andresearch: Application to clinical practice.American Journal of Orthopsychiatry 64:405–420.

Bowlby, J. (1979). The making and breaking ofaffectional bonds. New York: Tavistock.

Brown, S.A. (1993). Recovery patterns in ado-lescent substance abuse (pp. 161–183). InJ.S. Baer & G.A. Marlatt (eds.), Addictivebehaviors across the life span: Prevention,treatment, and policy issues. Newbury ParkCA: Sage Publications.

Burks, V.S., Dodge, K.A., Price, J.M., & Laird,R.D. (1999). Internal representation modelsof peers: Implications for the development ofproblematic behavior. Developmental Psy-chology 35: 802–810.

Byng-Hall, J. (1991). The application of at-tachment theory to understanding andtreatment in family therapy (pp. 199–215).In C.M. Parkes, J. Stevenson-Hinde, & P.Marris (eds.), Attachment across the life cy-cle. London: Routledge.

Byng-Hall, J. (1995). Creating a secure familybase: Some implications of attachment the-



ory for family therapy. Family Process 34:45–58.

Byng-Hall, J. (1999). Family and couple ther-apy: Toward greater security (pp. 625–645).In J. Cassidy & P.R. Shaver (eds.), Hand-book of attachment: Theory, research, andclinical applications. New York: GuilfordPress.

Chandler, M.J. (1987). The Othello effect: Es-say on the emergence and eclipse of skepti-cal doubt. Human Development 30: 137–159.

Cicchetti, D., & Toth, S. (1995). A developmen-tal psychopathology perspective on childabuse and neglect. Journal of the AmericanAcademy of Child & Adolescent Psychiatry34: 541–565.

Clark, D.B., Lesnick, L., & Hegedus, A.M.(1997). Traumas and other adverse lifeevents in adolescents with alcohol abuse anddependence. Journal of the American Acad-emy of Child and Adolescent Psychiatry 36:1744–1751.

Cobb, C.L.H. (1996). Adolescent-parent attach-ments and family problem-solving styles.Family Process 35: 57–82.

Collins, W.A. (1990). Parent-child relation-ships in the transition to adolescence: Con-tinuity and change in interaction, affect, andcognition (pp. 85–106). In R. Montemayor,G.R. Adams, & T.P. Gullotta (eds.), Fromchildhood to adolescence: A transitional pe-riod? Newbury Park CA: Sage Publications.

Conger, R.D., & Ge, X. (1999). Conflict andcohesion in parent-adolescent relations:Changes in emotional expression from earlyto midadolescence (pp. 185–206). In M.J.Cox & J. Brooks-Gunn (eds.), Conflict andcohesion in families: Causes and conse-quences. Mahwah NJ: Lawrence ErlbaumAssociates.

Dekovic, M. (1999). Risk and protective factorsin the development of problem behavior dur-ing adolescence. Journal of Youth and Ado-lescence 28: 667–685.

Diamond, G.M., Liddle, H.A., Hogue, A., &Dakof, G.A. (1999). Alliance-building inter-ventions with adolescents in family therapy:A process study. Psychotherapy 36: 355–368.

Diamond, G.S., & Liddle, H.A. (1999). Trans-forming negative parent-adolescent interac-tions: From impasse to dialogue. FamilyProcess 38: 5–26.

Dishion, T.J., & Patterson, G.R. (1997). Thetiming and severity of antisocial behavior:Three hypotheses within an ecological con-text (pp. 205–217). In D.M. Stoff, J. Breiling,& J.D. Maser (eds.), Handbook of antisocialbehavior. New York: John Wiley & Sons.

Doane, J.A., & Diamond, D. (1994). Affect andattachment in the family: A family-basedtreatment of major psychiatric disorder.New York: Basic Books.

Doane, J.A., Hill, W.L., Jr., & Diamond, D.(1991). A developmental view of therapeuticbonding in the family: Treatment of the dis-connected family. Family Process 30: 155–175.

Fonagy, P., Target, M., Steele, M., Steele, H.,Leigh, T., Levinson, A., & Kennedy, R.(1997). Morality, disruptive behavior, bor-derline personality disorder, crime, andtheir relationship to security of attachment(pp. 223–274). In L. Atkinson & K.J. Zucker(eds.), Attachment and psychopathology.New York: Guilford Press.

Gray, M.R., & Steinberg, L. (1999). Unpackingauthoritative parenting: Reassessing a mul-tidimensional construct. Journal of Mar-riage and the Family 61: 574–587.

Haley, J. (1976). Problem-solving therapy:New strategies for effective family therapy.San Francisco: Jossey Bass.

Henggeler, S.W., Schoenwald, S.K., Borduin,C.M., Rowland, M.D., & Cunningham, P.B.(1998). Multisystemic treatment of antisocialbehavior in children and adolescents. NewYork: Guilford Press.

Henry, B., Feehan, M., McGee, R., Stanton,W., Moffitt, T.E., & Silva, P.A. (1993). Theimportance of conduct problems and depres-sive symptoms in predicting adolescent sub-stance use. Journal of Abnormal Child Psy-chology 21: 469–480.

Hoffman, L. (1981). Foundations of familytherapy: A conceptual framework for systemschange. New York: Basic Books.

Holmbeck, G.N., & Updegrove, A.L. (1995).Clinical-developmental interface: Implica-tions of developmental research for adoles-cent psychotherapy. Psychotherapy 32: 16–33.

Johnson, S.M., Maddeaux, C., & Blouin, J.(1998). Emotionally focused family therapy


for bulimia: Changing attachment patterns.Psychotherapy 25: 238–247.

Kidwell, J.S., Fischer, J.L., Dunham, R.M., &Baranowski, M.D. (1983). Parents and ado-lescents: Push and pull of change (pp. 74–89). In H.I. McCubbin & C.R. Figley (eds.),Stress and the family, Vol. 1: Coping withnormative transitions. New York: Brunner-Mazel.

Kobak, R. (1999). The emotional dynamics ofdisruptions in attachment relationships:Implications for theory, research, and clini-cal intervention (pp. 21–43). In J. Cassidy &P.R. Shaver (eds.), Handbook of attachment:Theory, research, and clinical applications.New York: Guilford Press.

Lahey, B.B., Gordon, R.A., Loeber, R.,Stouthamer-Loeber, M., & Farrington, D.P.(1999). Boys who join gangs: A prospectivestudy of predictors of first gang entry. Jour-nal of Abnormal Child Psychology 27: 261–276.

Liddle, H.A. (1994). The anatomy of emotionsin family therapy with adolescents. Journalof Adolescent Research 9: 120–157.

Liddle, H.A. (1995). Conceptual and clinicaldimensions of a multidimensional, multisys-tems engagement strategy in family-basedadolescent treatment. Psychotherapy 32:39–58.

Liddle, H.A. (1999). Theory development in afamily-based therapy for adolescent drugabuse. Journal of Clinical Child Psychology28: 521–532.

Liddle, H.A. (2002). Multidimensional FamilyTherapy: A treatment manual. RockvilleMD: Center for Substance Abuse Treat-ment.

Liddle, H.A., Dakof, G.A., & Diamond, G.(1991). Adolescent substance abuse: Multi-dimensional family therapy in action (pp.120–171). In E. Kaufman & P. Kaufman(eds.), Family therapy of drug and alcoholabuse (2nd ed.). Needham Heights MA: Allyn& Bacon.

Liddle, H.A., Dakof, G.A., Parker, K., Dia-mond, G.S., Barrett, K., & Tejeda, M. (2001).Multidimensional Family Therapy for ado-lescent drug abuse: Results of a randomizedclinical trial. American Journal of Drug andAlcohol Abuse 27: 651–688.

Liddle, H.A., & Hogue, A. (2001). Multidimen-

sional family therapy for adolescent sub-stance abuse (pp. 229–261). In E.F. Wagner& H.B. Waldron (eds.), Innovations in ado-lescent substance abuse interventions. Am-sterdam: Elsevier Science.

Liddle, H.A., Rowe, C., Dakof, G., & Lyke, J.(1998). Translating parenting research intoclinical interventions for families of adoles-cents. Clinical Child Psychology and Psychi-atry 3: 419–443.

Liddle, H.A., Rowe, C., Diamond, G.M., Sessa,F.M., Schmidt, S., & Ettinger, D. (2000).Toward a developmental family therapy:The clinical utility of research on adoles-cence. Journal of Marital and Family Ther-apy 26: 485–500.

Lieberman, M., Doyle, A.-B., & Markiewicz, D.(1999). Developmental patterns in securityof attachment to mother and father in latechildhood and early adolescence: Associa-tions with peer relations. Child Develop-ment 70: 202–213.

Lindegger, G., & Barry, T. (1999). Attachmentas an integrating concept in couple and fam-ily therapy. Contemporary Family Therapy21: 267–288.

Luthar, S., & Cicchetti, D. (2000). The con-struct of resilience: Implications for inter-ventions and social policies. Developmentand Psychopathology 12(4): 857–885.

Maccoby, E.E. (1992). The role of parents inthe socialization of children: An historicaloverview. Developmental Psychology 28:1006–1017.

Maio, G.R., Fincham, F.D., & Lycett, E.J.(2000). Attitudinal ambivalence toward par-ents and attachment style. Personality andSocial Psychology Bulletin 26: 1451–1464.

Newcomb, M.D., & Loeb, T.B. (1999). Poor par-enting as an adult problem behavior: Gen-eral deviance, deviant attitudes, inadequatefamily support and bonding, or just bad par-ents? Journal of Family Psychology 13: 175–193.

Nurco, D.N., Blatchley, R.J., Hanlon, T.E., &O’Grady, K.E. (1999). Early deviance andrelated risk factors in the children of nar-cotic addicts. American Journal of Drug andAlcohol Abuse 25: 25–45.

Ohannessian, C.M., Lerner, R.M., Lerner,J.V., & von Eye, A. (1998). Perceived paren-tal acceptance and early adolescent self-



competence. American Journal of Orthopsy-chiatry 68: 621–629.

Palmer, E.J., & Hollin, C.R. (2001). Sociomoralreasoning, perceptions of parenting, andself-reported delinquency in adolescents.Applied Cognitive Psychology 15: 85–100.

Patterson, G.R., Bank, L., & Stoolmiller, M.(1990). The preadolescent’s contributions todisrupted family process (pp. 107–133). InR. Montemayor, G.R. Adams, & T.P. Gul-lotta (eds.), From childhood to adolescence:A transitional period? Newbury Park CA:Sage Publications.

Rodgers, K.B. (1998). Parenting practices re-lated to sexual risk taking behaviors of ad-olescent males and females. Journal of Mar-riage and the Family 60: 99–109.

Rosenstein, D.S., & Horowitz, H.A. (1996). Ad-olescent attachment and psychopathology.Journal of Consulting and Clinical Psychol-ogy 64: 244–253.

Rutter, M. (1997). Clinical applications of at-tachment concepts: Retrospect and prospect(pp. 47–93). In L. Atkinson & K.J. Zucker(eds.), Attachment and psychopathology.New York: Guilford Press.

Rutter, M., & Sroufe, L.A. (2000). Develop-mental psychopathology: Concepts and chal-lenges. Development and Psychopathology12: 265–296.

Schmidt, S.E., Liddle, H.A., & Dakof, G.A.(1996). Changes in parenting practices andadolescent drug abuse during multidimen-sional family therapy. Journal of FamilyPsychology 10: 12–27.

Sexson, S.B., Glanville, D.N., & Kaslow, N.J.(2001). Attachment and depression: Impli-cations for family therapy. Child and Ado-lescent Psychiatric Clinics of North America10: 465–486.

Shaw, D.S., Bell, R.Q., & Gilliom, M. (2000). Atruly early starter model of antisocial behav-ior revisited. Clinical Child and Family Psy-chology Review 3(3): 155–172.

Shirk, S., Talmi, A., & Olds, D. (2000). A de-velopmental psychopathology perspectiveon child and adolescent treatment policy.Development and Psychopathology 12: 835–855.

Silverberg, S.B. (1996). Parents’ well-being attheir children’s transition to adolescence(pp. 215–254). In C.D. Ryff & M.M. Seltzer(eds.), The parental experience at midlife.Chicago: University of Chicago Press.

Silverberg, S.B., & Gondoli, D.M. (1996). Au-tonomy in adolescence: A contextualizedperspective (pp. 12–61). In G.R. Adams, R.Montemayor, & T.P. Gullotta (eds.), Psycho-social development in adolescence: Progressin developmental contextualism. ThousandOaks CA: Sage Publications.

Sroufe, L.A. (1988). The role of infant-care-giver attachment in development (pp. 18–38). In J. Belsky & T. Nezworski (eds.), Clin-ical implications of attachment. HillsdaleNJ: Lawrence Erlbaum Associates.

Steinberg, L., & Levine, A. (1977). You andyour adolescent: A parent’s guide for ages 10to 20. New York: Basic Books.

Steinberg, L., & Silverberg, S.B. (1986). Thevicissitudes of autonomy in early adoles-cence. Child Development 57: 841–851.

Tacon, A.M., & Caldera, Y.M. (2001). Attach-ment and parental correlates in late adoles-cent Mexican American women. HispanicJournal of Behavioral Sciences 23: 71–87.

Tarter, R., Vanyukov, M., Giancola, P., Dawes,M., Blackson, T., Mezzich, A., & Clark, D.B.(1999). Etiology of early age onset substanceuse disorder: A maturational perspective.Development and Psychopathology 11: 657–683.

Thompson, R.A. (1999). Early attachment andlater development (pp. 265–286). In J.Cassidy & P.R. Shaver (eds.), Handbook ofattachment: Theory, research, and clinicalapplications. New York: Guilford Press.

Weinfield, N.S., Sroufe, L.A., & Egeland, B.(2000). Attachment from infancy to earlyadulthood in a high-risk sample: Continuity,discontinuity, and their correlates. ChildDevelopment 71: 695–702.

Woodward, L., Fergusson, D.M., & Belsky, J.(2000). Timing of parental separation andattachment to parents in adolescence: Re-sults of a prospective study from birth to age16. Journal of Marriage and the Family 62:162–174.


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