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Attachment Based Care (ABC) Millieu Program

The Attachment Based Care Milieu Program is a multi-tier program which teaches organizations to use attachment theory as a unifying clinical framework for all members of the treatment team. It was developed by Ilse Devacht at Asster Hospital in Belgium in collaboration with the ABFT Training Program and Professor Guy Bosmans at KU Leuven University in Belgium. The ABC Milieu Program is typically applied in inpatient or residential treatment facilities and focused on administrators, doctors, nurses, therapists, line staff and support staff. The goal is to encourage the milieu staff to take a more psychotherapeutic approach to milieu management, in contrast to the more typical behavioral management approach. While managing safety on the milieu is critical, an attachment based approach helps staff see how some behaviors are interpersonal needs that are poorly expressed. In this model, conflict, cooperation, and program resistance are viewed as therapeutic opportunities rather than barrier to treatment.

Critical to this approach is the application of attachment-based family therapy as the organizing clinical intervention model. Therapists view attachment ruptures (e.g., family conflicts, negative emotional climate, etc.) as a major contribution to the patients’ problems. Sometimes these conflicts can cause teens to have problems (e.g. divorce, parental alcoholics), and sometimes these conflicts can deny the teen the support they need to overcome their challenges. When the therapist in family sessions is working through attachment ruptures and the milieu staff can interpret milieu behavior as attachment needs, there is an intensive therapeutic experience for the patient. This approach has also been observed to reduce conflicts on the units, reduce episodes that require restraints/seclusion and improve treatment satisfaction.

The Attachment Based Milieu Program does not impede the use of any treatment or milieu component already being used such as CBT, MBT, 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 the work already being conducted. The program can be implemented, regardless of the diagnoses or age of patients.

Implementing the Attachment Based Care Milieu Program requires more than a three-day training program alone. Behavioral change of a system is never easy. Leadership and management must be engaged in the change process and staff need ongoing guidance and support.

The Attachment Based Care Milieu Program consists of two components.

Component One

Component One is comprised of three parts which build on one another. Organizations do not have to participate in all three parts, however we find that true change on the milieu is difficult without implementing the full program.

Part I: Attachment Based Milieu Team Training

For (interdisciplinary) teams, the program offers a three-day team training. The first day, on Attachment principles and practice, can be offered as a standalone workshop. The second day is a training day on conversation skills, focusing on unraveling attachment themes and ruptures from the patient’s story and on creating corrective attachment experiences with caretakers and peers in the treatment milieu. The third day is about shaping the treatment milieu into a safe attachment learning environment. Therapy program design, setting rules, prevention and handling of acting-out, are topics addressed in this tailor-made third day workshop.

In order for the milieu training to translate into change on the unit, a change agent/champion on the team needs to be identified that will lead this change process and support the team. The person best suited to act as the change agent is a family therapist on the team who will also be trained in ABFT. However, other change agents can be considered with the organization.

Workshop Scheduling

As noted above, the first day of the training can be a standalone workshop. The three days can be delivered in one training or the first day can be delivered alone and then days two and three can be delivered days/weeks/months after the first day. All milieu staff need to attend Days 1 and 3 together. Day 2 is intended to be conducted with smaller groups of staff (12-20 people) and can be conducted in two groups (i.e., have Day 2 twice) to respect the need to keep the unit running during the training.

Part II: Milieu Team Supervision

Supervision is provided on a monthly basis online to help multidisciplinary teams implement the milieu training and adapt existing systems (when necessary) to be consistent with the milieu model. Additionally, supervision serves as a place for team members to process challenges professionally and interpersonally in utilizing this new model.

Supervision by an accredited ABFT therapist-trainer, of teams implementing the Attachment Based Care Milieu Program, is provided online for 6 months and then the change agent will take over this process.

Requirements for Participation

Participants must have attended the three-day milieu training (or 3-hour booster session) to participate in supervision.

Part III: Milieu Change Agent Supervision

For ongoing utilization of the milieu model, a coach/change agent is needed to facilitate the implementation of the program into all levels of care on a unit or facility. The program provides assistance in selection and supervision of this facilitator’s role. We also train 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. We advise a minimum of two years, monthly facilitator’s supervision.

Component Two

ABFT Therapist Training

Including patients’ primary attachment relationships in the recovery and healing of the patient, means the implementation of attachment-based family therapy (ABFT) into treatment. At least one therapist needs to be trained in ABFT in order to provide clients with family therapy. This training is offered in Philadelphia or onsite on demand. For teams consisting of multiple therapists working with families in family therapy, we advise training at least one supervisor and 2 therapists at a minimum per team in order to create meaningful change and impact.

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 Milieu 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."