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Attachment Based Care for Teams (ABC4T) Program

Overview of the ABC4T Program

The Attachment Based Care for Teams (ABC4T) program is a multi-phased, trauma-informed training program to help bring a more unified, trauma informed, attachment promoting clinical framework to the entire treatment team. ABC4T is about helping caregivers and staff members to be a secure base for children and young people (CYP) to support their developing autonomy and competency. This means conceptualizing distress and change from an attachment lens, helping family members repair and strengthen their parent – child relationships and supporting staff to engage as temporary attachment figures to the CYP within a relationally safe learning climate on the unit.

The program consists of three stages. First, a pre-training phase to understand the culture and structure of the unit. Second, a training phase where therapists learn Attachment-Based Family Therapy and all staff learn the Attachment-Based Care for Teams Program. Third, a sustainability phase where ongoing supervision and consultation helps the team and change agent on site integrate the ABC4T Program into every day practice.

Aims of the Program

The ABC4T Program works with administrators, doctors, nurses, therapists, line and support staff in inpatient, residential, partial hospital, and day treatment facilities. The program helps the entire staff to take a more psychotherapeutic approach to milieu management, in contrast to the more typical behavioral management models. While managing safety is critical, an attachment-based lens, is grounded in trauma informed care models. This helps staff understand patient behaviors as emerging from unmet interpersonal needs that are poorly expressed. Conflicts and resistance become therapeutic opportunities rather than barriers to treatment.

The ABC4T Program promotes an atmosphere of safety and trust for both patients and their families. Transparency and collaboration become key therapeutic elements. As consumers feel safer, staff can challenge patients to identify unexplored trauma and disappointments while helping caregivers develop more emotion-focused, attachment promoting parenting skills (e.g. warmth and structure). Staff shore up caregivers to provide a more developmentally secure and growth-promoting family environment.

Critical to milieu change is the application of attachment-based family therapy as a primary psychosocial clinical intervention model. ABFT therapists view attachment ruptures (e.g., family conflicts, negative emotional climate, etc.) as a strong contributor to the patients’ problems. Sometimes these conflicts (e.g. divorce, caregiver depression) cause teens to have problems, and sometimes these conflicts deny the adolescent the necessary support her or she needs to overcome adversity, whether it is environmental (e.g., bullying) or internal (e.g., bi-polar disorder). ABFT does not assume all problems are family-based. Youth with psychiatric challenges can become destabilized even in the best of families. Building CBT or DBT skills, or medication remain critical elements of the multi-modal treatment program. However, family therapy becomes a bigger aspect of the psychosocial treatment approach.

Extending the attachment informed clinical framework to the milieu has several benefits. First, work in the milieu can support work in the family sessions and vice versa. For example, when the family sessions focus on trauma, group and individual therapy can take up similar themes. When patients act out on the unit, rather than punish the behavior, staff understand it as a partial reaction to the trauma focused therapy which can guide how staff intervene in the behavior and hold the patient accountable. Second, the teen experiences the inpatient or residential work as more integrated. When staff can interpret milieu behavior as attachment needs, or reactions to the intense family work, the therapeutic framework becomes more coherent and consistent. Third, patients and caregivers experience the staff as more unified in their approach to clinical challenges. All clinical and milieu staff have a shared understanding, clinical vocabulary, intervention strategies and desired outcome. Finally, staff morale and job satisfaction can increase when the disconnect between frontline staff and clinical staff can be reduced. In an attachment based, trauma informed program, all staff are valued as part of the clinical team with shared and unique contributions to make.

The ABC4T Program does not impede the use of any treatment or milieu component already in place, such as CBT, MBT, DBT, NVR, Signs of Safety, etc. Programs can proceed with what already works for their team and the patients they treat. Attachment principles and working with primary attachment relationships will ground these interventions in a more developmental and strength-based treatment framework. The program can be implemented regardless of age of patients. Even young adults have unresolved issues with caregivers they live with, or the young adult may live alone but are dependent on caregivers because of their mental health issues. Attachment-based care is trans-diagnostical, trans-age and trans-framework. It is ‘basic’ in a lot of ways. The program can be implemented regardless of disorder. Families can support recovery or exacerbate conflict; if we can help caregivers, they can be helpful to their child.

The Attachment Based Care Milieu Program consists of three components:

Component One: Pre-Training

Component One is comprised of a series of meetings with the unit’s staff (nursing, therapists, educational staff) and unit leadership (medical leadership including doctors, clinical leads and managers). Step 1 is a two-hour online meeting with nursing staff. Step 2 is a 2-hour online meeting with representatives of therapists including dieticians, OT, PM and educational staff. The meetings will help the ABC4T trainer understand the organizational structure, values, staffing roles, workflow, chain of command, infrastructure, and when and how families are included. During the pre-training meetings, we also seek to understand the current culture of the unit and help the organization think about how to sustain the impact of the work we are about to do. During the pre-training meetings, we will also orient the staff to the training and gather baseline data. Step 3 is a “Day 0 Workshop” (2-hour online meetings) with leadership wherein the unit leadership analyze the Strengths, Weaknesses, Opportunities and Threats (SWOTS) of the unit. There will also be a 1-hour follow-up meeting with leadership to prepare for training.

Component Two: Training

Component Two is comprised of two training tracks.

Track I: Attachment-Based Family Therapy Therapist Training

Patients’ primary attachment relationships need to be included in the recovery and healing of adolescents. Attachment-based family therapy (ABFT) is a manualized, empirically supported family therapy model specifically designed to target family and individual processes associated with adolescent suicide and depression. ABFT emerges from interpersonal theories that suggest adolescent and young adult internalizing disorders (e.g., depression, suicide, trauma, anxiety) can be precipitated, exacerbated, or buffered against by the quality of interpersonal relationships in families. It has also been used where family conflict is a contributor to the presenting problem. It is a trust-based, emotion-focused psychotherapy model that aims to repair interpersonal ruptures and rebuild an emotionally protective, secure-based parent–child relationship.

There are three levels to ABFT training with each building from Level I (3-day in-person/online or 6 half-day online workshop). Level II involves group supervision (22, fortnightly sessions) and an advanced workshop (3-day in-person/online or 6 half-day online workshop). Level III which leads to certification, requires therapists to submit 10 recorded therapy sessions for in-depth feedback and adherence rating. Please see the ABFT Training page for more information.

For the ABC4T training to translate into change on the unit, there must be a change agent/champion staff member on the team. At least one family therapist training in attachment-based family therapy (ABFT) to the level of certified ABFT therapist will support the team members in the change process.

Track II: Attachment Based Care for Teams Training (ABC4T)

For (interdisciplinary) teams, the program provides a three-day team training.

Day 1: The first day focuses on attachment principles and practice. This day is offered as 9 pre-recorded podcasts that staff may listen to on their own time (2 hours and 30 minutes) and 3-hour live group exercises led by a trainer (in-person). All staff (full and part-time including domestic, RMSS, nurses, doctors, physical therapist, psychologists, family therapists, managers, occupational therapists, etc.) are required to listen to the lectures. The exercises will be offered two times to allow for coverage on the unit. For example, half of the Unit staff would attend in the morning and the other half would attend in the afternoon. At least 80% of the following staff from each unit are required to participate in exercises exploring the principles in the pre-recorded lectures (health care assistants, junior doctors, RMNS, family therapists, occupational therapists, creative therapy/dance movement/art/other, psychologists, social workers, dietetics, education, head teacher/ teaching assistants etc. This core group of staff will continue with the remaining of the training (CORE).

Day 2: The second day is a training day on skills including emotion coaching skills, building a bond with patients, how to listen and help clients make meaning, marking successes, confronting patients, dealing with resistance, learning to repair relationships with patients and learning how to talk with parents. Day 2 also focuses on understanding attachment themes and ruptures from the patient’s story and on facilitating corrective attachment experiences with staff caretakers and peers in the treatment milieu.

Day 2 will be offered two times to allow for CORE staff to attend and have coverage on each unit. Up to 25 people may attend each offering of Day 2 (50 total).

Day 3: The third day is about using attachment principles to modify the structuring and processes of the milieu to promote a more “secure base” learning environment. Topics include program design, setting rules, prevention and handling of acting-out behavior.

Day 3 will be offered one time. Staff coverage for the unit will be needed when the CORE staff attend Day 3

Component Three: Sustainability (optional)

While the training phase lays the foundation for applying the ABC4T framework, to really create systems change and sustainability we recommend the services listed below. However, we also recognize that these activities are not always feasible for a unit to engage in; therefore, they are optional activities.

ABC4T Team Intervision:

To sustain the learning from the three-day workshop, an approved ABC trainer provides web-based (2 hours) intervision monthly to help CORE staff on each unit implement the milieu training with clients. Additionally, intervision serves as a place for team members to process organizational and interpersonal challenges when integrating this new model. Six months of intervision (6 sessions) is recommended. After 6 sessions, the change agent takes over the intervision.

Requirements for participation:

Participants must have attended the three-day ABC4T training (or 3-hour booster session – see below) to participate in intervision.

ABC4T Change Agent Supervision:

For sustainability, the change agent will facilitate use of the program at all levels of care on a treatment unit. Fortnightly web-based group supervision is provided to support change agents. It I is recommended that change agents participate in supervision for one year (22 sessions, 90-minutes each).

Booster Session Training:

The ABC4T trainer also trains the change agent in a 3-hour booster training that the change agent can deliver to new staff that is hired to help them adapt and engage in the attachment-based care environment. This training will be provided online.

ABC4T Program Consultation

To ensure programmatic change discussed in the three-day workshop, an approved ABC4T trainer provides web-based consultation meetings to the unit to assist the team in adapting existing processes to be consistent with the ABC4T model. During these meetings, it is recommended that as much CORE staff as possible is needed to take part in these meetings to ensure systemic change. The team may opt for as many ABC4T Program Consultation sessions as desired. A minimum of one is recommended.

Client Feedback

This program has been implemented and is being evaluated in a young adult inpatient hospital program. Clients and staff have provided feedback on their experiences. Those who have engage in the Attachment Based Care for Teams Program have experienced:

Increased patient engagement

  • "I want to come continue treatment for the ABFT sessions. Things are really starting to change at home. My dad listens to me now. And I’m listening to him."

Increased parent satisfaction

  • "After so many hospitalizations for our adoptive son, we’ve now experienced psychiatry can be different, can make a difference."

Increased team member resilience

  • "Every time we discuss a case from the attachment perspective we’re trained in, we see new options for care and treatment. We find hope again in seemingly hopeless cases."

Augmented team efficiency

  • "Our treatments go deeper and target what really matters now. Since we’ve adopted the Attachment Based Treatment Program, we know what we are doing. We share moments of proudness of our work with vulnerable young people."

Program Outcomes

To evaluate the effectiveness of the ABC program, we aim to collect several outcome indicators. We propose collecting baseline (two years) data and then quarterly data for two years as the program matures. We ask for the rates of the following list of data elements:

  1. AMA discharges
  2. Patient restraint or disciplinary incidents
  3. Customer satisfaction with overall program
  4. Staff work satisfaction
  5. Staff turn over
  6. Patient outcomes (e.g., depression, suicidality, well-being)
  7. Readmissions