Barriers and Facilitators to Implementing Attachment-based Family Therapy into a Child Welfare Setting: A Qualitative Process Evaluation

The use of Open Dialogue in Trauma Informed Care services for mental health consumers and their family networks: A scoping review

WHAT IS KNOWN ON THE SUBJECT?: Open Dialogue was developed in Finland in the 1980s by clinical psychologist, Jaakko Seikkula. It is a development of family therapy, recognises previous trauma and has proven to be very effective in situations of acute mental illness, and in particular psychosis. Trauma Informed Care is a practice based on the understanding of and responsiveness to the impact of trauma. When people have experienced trauma, they may have difficulties in their everyday life and experience negative physical health outcomes as well as the risk of developing mental ill health. Open Dialogue is aligned to mental health care which aims to be trauma-informed, person-centred and rights-based. Examples exist of the use of both approaches for service delivery with limited evaluation. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no formal evaluation has been made of the use of open dialogue as a Trauma Informed therapy approach to support individuals and their family networks. Although both approaches recognise the impact of trauma on individuals, no study has explored the effectiveness of this treatment combination for use by mental health nurses. This review is timely as it provides insights into contemporary services that are trauma informed and have used Open Dialogue to extend therapy work with individuals and their family/networks. This scoping review was able to determine whether recommendations for clinical practice and training in Open Dialogue with Trauma Informed Care approaches could be identified. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review provided a broad overview on the current types of trauma-informed care services incorporating Open Dialogue approaches into their practice. The literature, though sparce, identifies that Trauma Informed Care recognises multiple origins for mental ill health. Open dialogue has an affinity with the common values of mental health nurses. As combined therapies, they are demonstrating usefulness in engaging families and people in their journey towards recovery. Rigid adherence to Open Dialogue focus and delivery as well as training practices could be revised to make them more open to what people and their families wish to discuss. The person with mental ill health and previous trauma should be able to direct the narrative. Trauma Informed Practice principles could be adapted to improve consumer satisfaction with Open Dialogue approaches.

ABSTRACT

INTRODUCTION: A large proportion of people who access mental health services have a lived experienced of trauma and are more likely to have a history of complex trauma. Open Dialogue and Trauma Informed Care practices identify previous trauma as a factor related to later psychosis. This scoping review has identified similarities and contrasts in how an Open Dialogue and Trauma Informed Care approach have been combined to complement one another for clinical work with people presenting with psychosis and previous trauma.

AIM

We aimed to answer the following research question in this scoping review: What is known of the combined use of Open Dialogue and Trauma Informed Care practice when working with consumers and their family networks? As such, the purpose of this paper was to explore the application to practice and identify if any training existed and been evaluated.

METHOD

This scoping review was based on the Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases. Grey literature was also searched through Psyche Info and Google Scholar for books, Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2013 to January 2023.

RESULTS

Five distinct themes were identified from the literature: (1) Linking open dialogue with trauma, (2) Response to treatment, (3) Empowerment and information sharing, (4) Interpretation by clinical services, (5) Staff training outcomes.

DISCUSSION

Some tentative recommendations for practice recognised the individuals' unique story and perspective, suggested that trauma is an important concept to assess. Services practising as Trauma Informed Services that have incorporated an Open Dialogue approach have mixed experiences. The use of Open Dialogue may have some benefits for family work and exploring consumer narratives while building a network of support. However, consumers identified similar frustrations with service delivery as with the family therapy literature. For example, it was difficult to bring family members together and difficult to discuss previous traumatic events in front of family. People experiencing training in Open Dialogue reported it taking a slow pace and not what they were familiar with.

IMPLICATIONS FOR PRACTICE

Open Dialogue can facilitate engagement of consumers and their family networks and greater recognition of the peer workforce to promote collaboration in therapy is needed. Future research should also focus on evaluating the effectiveness of such services and comparing their outcomes across regions.

Attachment-Based Family Therapy for Adolescents and Young Adults With Suicide Ideation and Depression

Background: Suicide ideation among adolescents is difficult to treat. Attachment-based family therapy (ABFT) is a promising evidence-based family intervention developed to decrease depressive symptoms and suicide ideation among adolescents. Aims: This open trial assessed the feasibility of ABFT for adolescents (12-23 years) with suicide ideation and depression in an outpatient community mental health center in the Netherlands, by monitoring treatment compliance and satisfaction, treatment dose, and symptom reduction. Methods: Eligible patients were referred by the multidisciplinary treatment team at the facility. Treatment dose was monitored by the therapist. Depression (CDI-2), family functioning (SRFF), and strengths and difficulties (SDQ) were assessed online before the intervention and at 3, 6, and 9 months after baseline. Suicide ideation (SIQ-JR) was assessed at each therapy session, and a satisfaction questionnaire was administered postintervention. A total of 25 families signed informed consent, received ABFT treatment, and were included in the analyses. The therapists were at beginners' level of ABFT, working under supervision during the trial. Results: The treatment dose was acceptable, though impacted by COVID-related lockdowns, and treatment compliance was 89%. Patients received on average 22 ABFT sessions, and about half of the patients received additional psychotherapy. On average, patients were satisfied with ABFT. There was a significant decrease in suicide ideation postintervention (d = 0.69) and significant effects on the CDI-2, SRFF, and SDQ at follow-up with medium-to-large effect sizes (d = 0.53-0.94). Limitations: These results should be interpreted with considerable caution, as there was no control group to establish the effectiveness of ABFT, and the sample was small. Conclusion: ABFT appears to be a feasible therapy for youth with depression and suicide ideation in an outpatient community mental health setting.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Review of family-based treatments from 2010 to 2019 for suicidal ideation and behavior

Suicide ideation and behavior are pervasive public health issues. Given that positive interpersonal relationships can be a protective factor against suicide risk, we conducted a systematic review to examine peer-reviewed publications from 2010 to 2019 that included empirical data, tested an intervention with at least some family component, and included a suicide-related outcome measure. We reviewed and synthesized findings from 22 articles covering 7 intervention categories with 12 interventions to examine the treatment components and the quality of evidence to support them. Using Southam-Gerow and Prinstein's (Child Adolesc Psychol 43:16, 2014) guidelines, we identified two well-established intervention categories that met the highest standards for interventions and three probably efficacious intervention categories. All interventions found focused solely on suicide risk in adolescent populations. More studies are needed for adult populations and to explore the role of family moderators and mediators to test whether suicide outcomes are reduced by improvement in the family environment.

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

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