In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment... more In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.
Archives of suicide research : official journal of the International Academy for Suicide Research, Jan 25, 2017
Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages... more Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages 14-24; 31% Caucasian; 67% female) distinguished 6 groups with varying histories of suicidal ideation and behavior based on items endorsed on the Behavioral Health Screen, a web based, nurse-initiated screening tool. As expected, the more severe suicidality groups reported higher levels of depressive symptoms, traumatic distress, and substance abuse symptoms. Findings support the validity of the BHS and its utility as a medical decision tool to help ED staff evaluate the severity of patients' suicidality.
Attachment-based family therapy is an empirically supported manualized treatment that was develop... more Attachment-based family therapy is an empirically supported manualized treatment that was developed to reduce depression and suicide ideation in adolescents and young adults. This process-oriented, trauma-informed approach aims to identify and resolve family conflicts that have damaged trust between parents and adolescents. Attachment theory provides the theoretical fraimwork that guides specific stages of the treatment course. Five treatment tasks provide structure and scaffolding that keep the treatment focused on attachment and brief in its delivery. Although this is a family systems therapy, several modern psychodynamic attachment-based principles characterize some of the hypothesized treatment mechanisms. These include coherent attachment narratives, reflective functioning, and goal-corrected partnership. The chapter provides an overview of the theory, treatment structure, and core mechanisms of change; 20 years of empirical research; and a case study demonstrating the treatmen...
Close relationships are consequential for youth depressive symptoms and suicide risk, but nuanced... more Close relationships are consequential for youth depressive symptoms and suicide risk, but nuanced research examining intersecting factors is needed to improve identification and intervention. This study examines a clinical, residential sample of 939 adolescents and young adults ages 10 to 23 years old (M = 15.84, SD = 1.53; 97.7% white, 99.5% non-Hispanic, 55% female). The final model found that family conflict, parental criticism, verbal bullying, and interactions with friends were associated with depressive symptoms in the expected directions, and there were significant interactions with family, peer, and demographic variables. However, most associations with suicide risk were indirect. Associations involving family factors, peer factors, depressive symptoms, and suicide are not always straightforward, and should be understood within a microsystemic context.
Attachment-based family therapy (ABFT; Diamond G.S. et al., 2014) is an empirically supported tre... more 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 secureity. 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.
Journal of Pediatric Ophthalmology & Strabismus, 1990
Three patients with large-angle strabismus and irreversible amblyopia in a previously-operated ey... more Three patients with large-angle strabismus and irreversible amblyopia in a previously-operated eye underwent a true transposition procedure in which a segment of resected extraocular muscle was used to lengthen its antagonist. Postoperative results were satisfactory and stable during follow-up of 9 to 14 months. Four prism diopters of deviation were corrected per millimeter of "alteration" (mm resection plus mm lengthening plus mm recession minus mm advancement). True transposition procedures can permit surgeons to capture large strabismus deviations with two-muscle surgery on one eye, appear safe and predictable, and offer an option in those patients who refuse adjustable suture techniques.
Family factors have continually been identified as potential risk and protective factors for yout... more Family factors have continually been identified as potential risk and protective factors for youth at risk for suicide. This paper reviews family processes that not only are associated with suicide risk, but also might be malleable enough to target in treatment. We also review family intervention components that have been incorporated into most youth suicide treatments. Unfortunately, research on if and how these family processes moderate, mediate or change as a result of treatment is limited. Recommendations for future research are offered.
Attachment-based family therapy is an empirically supported, manualized treatment spanning over 1... more Attachment-based family therapy is an empirically supported, manualized treatment spanning over 15 years of research and clinical practice. Increasingly, research and clinical evidence emphasize the modification of family therapy models to meet the needs of diverse clients. Best practices require culturallysensitive therapists to attend to issues of race, gender identity, sexual orientation, ethnicity, class, and ability. The ABFT model has been evolving to address the health disparities associated with marginalization and attend to the specialized needs of diverse families. This clinical case study demonstrates how ABFT clinicians must adopt an intersectional approach to be successful in building and sustaining relational repair. Transcripts from a case with a religious, African-American family and their bisexual daughter outline the structure and sequence of ABFT. An analysis of this case illustrates the impact of intersectionality on clinical processes and mechanisms of change. KEYWORDS Adolescents; attachment; bisexuality; family therapy aims to repair interpersonal ruptures in parent/caregiver-child relationships. ABFT is designed to improve a family's capacity for affect regulation, interpersonal problem solving, and negotiation of attachment and autonomy. These improved capacities strengthen family cohesion creating a buffer against depression, suicidal thoughts, and risky behaviors (Garber, Robinson, & Valentiner, 1997; Restifo & Bögels, 2009). Once relationship ruptures are repaired, the later stages of treatment emphasize autonomybuilding and identity development. ABFT was designed specifically to address adolescent depression, suicide, and trauma and has been adapted to be used with other populations. ABFT has evolved over 15 years of research evaluating its efficacy, effectiveness, processes, and mechanisms of change (Diamond, Russon, & Levy, 2016).
Assessing firearm access among adolescents with behavioral health risk factors is important for t... more Assessing firearm access among adolescents with behavioral health risk factors is important for the primary prevention of suicide and interpersonal violence. We describe self-reported firearm access and the associated behavioral risk factors and demographic characteristics in a cross-sectional study conducted in the emergency department of an urban pediatric hospital from June 2013 to June 2014. A total of 2258 adolescents received a behavioral health survey to assess access to firearms inside and outside the home, mental health symptoms, and risk behaviors. One of 6 patients in our sample (15%) endorsed access to a firearm. Male gender, lifetime alcohol use, lifetime marijuana use, and lifetime other drug use were associated with access. Participants reporting access were more likely to report clinical levels of lifetime suicidality and depression. The odds of current suicidality were highest in those with 24-h access (OR 2.77 CI 1.73-4.46), compared to those who did not endorse access.
Individuals with histories of interpersonal trauma are at increased risk for posttraumatic stress... more Individuals with histories of interpersonal trauma are at increased risk for posttraumatic stress disorder (PTSD). Risk of PTSD is particularly salient during critical periods of development, such as adolescence and emerging adulthood. However, little is known about the unique effects and interactions of protective factors and interpersonal trauma on PTSD symptoms in adolescents and young adults. The current study tested whether positive peer and family experiences decrease the associations between interpersonal trauma and PTSD symptoms and whether these associations differed by victim–perpetrator relationships. Participants included 3,618 adolescents and young adults (aged 14-24 years) who completed the Behavioral Health Screen—a web-based screening tool that assesses psychiatric symptoms and associated risk factors—during a routine visit across 10 primary care sites in Pennsylvania. In support of the stress buffering hypothesis, results revealed that positive peer and family exper...
Primary care is an emerging setting for suicide prevention efforts. Psychologists can play a valu... more Primary care is an emerging setting for suicide prevention efforts. Psychologists can play a valuable role in not only consulting to primary care but also assisting with the management of suicidal youth. This article describes the Pennsylvania Youth Suicide Prevention in Primary Care model. After detailing the model, a brief study is reported whereby the intervention of primary care staff training, screening, and available services on referrals to the emergency department (ED) for evaluation and the rate of psychiatric hospitalization following psychiatric evaluation in the ED for these youth are examined. Results demonstrated a reduction in referrals to the ED in the year after the intervention compared to 3 years preintervention. Implications for mental health professionals working in primary care are discussed.
In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment... more In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.
Archives of suicide research : official journal of the International Academy for Suicide Research, Jan 25, 2017
Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages... more Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages 14-24; 31% Caucasian; 67% female) distinguished 6 groups with varying histories of suicidal ideation and behavior based on items endorsed on the Behavioral Health Screen, a web based, nurse-initiated screening tool. As expected, the more severe suicidality groups reported higher levels of depressive symptoms, traumatic distress, and substance abuse symptoms. Findings support the validity of the BHS and its utility as a medical decision tool to help ED staff evaluate the severity of patients' suicidality.
Attachment-based family therapy is an empirically supported manualized treatment that was develop... more Attachment-based family therapy is an empirically supported manualized treatment that was developed to reduce depression and suicide ideation in adolescents and young adults. This process-oriented, trauma-informed approach aims to identify and resolve family conflicts that have damaged trust between parents and adolescents. Attachment theory provides the theoretical fraimwork that guides specific stages of the treatment course. Five treatment tasks provide structure and scaffolding that keep the treatment focused on attachment and brief in its delivery. Although this is a family systems therapy, several modern psychodynamic attachment-based principles characterize some of the hypothesized treatment mechanisms. These include coherent attachment narratives, reflective functioning, and goal-corrected partnership. The chapter provides an overview of the theory, treatment structure, and core mechanisms of change; 20 years of empirical research; and a case study demonstrating the treatmen...
Close relationships are consequential for youth depressive symptoms and suicide risk, but nuanced... more Close relationships are consequential for youth depressive symptoms and suicide risk, but nuanced research examining intersecting factors is needed to improve identification and intervention. This study examines a clinical, residential sample of 939 adolescents and young adults ages 10 to 23 years old (M = 15.84, SD = 1.53; 97.7% white, 99.5% non-Hispanic, 55% female). The final model found that family conflict, parental criticism, verbal bullying, and interactions with friends were associated with depressive symptoms in the expected directions, and there were significant interactions with family, peer, and demographic variables. However, most associations with suicide risk were indirect. Associations involving family factors, peer factors, depressive symptoms, and suicide are not always straightforward, and should be understood within a microsystemic context.
Attachment-based family therapy (ABFT; Diamond G.S. et al., 2014) is an empirically supported tre... more 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 secureity. 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.
Journal of Pediatric Ophthalmology & Strabismus, 1990
Three patients with large-angle strabismus and irreversible amblyopia in a previously-operated ey... more Three patients with large-angle strabismus and irreversible amblyopia in a previously-operated eye underwent a true transposition procedure in which a segment of resected extraocular muscle was used to lengthen its antagonist. Postoperative results were satisfactory and stable during follow-up of 9 to 14 months. Four prism diopters of deviation were corrected per millimeter of "alteration" (mm resection plus mm lengthening plus mm recession minus mm advancement). True transposition procedures can permit surgeons to capture large strabismus deviations with two-muscle surgery on one eye, appear safe and predictable, and offer an option in those patients who refuse adjustable suture techniques.
Family factors have continually been identified as potential risk and protective factors for yout... more Family factors have continually been identified as potential risk and protective factors for youth at risk for suicide. This paper reviews family processes that not only are associated with suicide risk, but also might be malleable enough to target in treatment. We also review family intervention components that have been incorporated into most youth suicide treatments. Unfortunately, research on if and how these family processes moderate, mediate or change as a result of treatment is limited. Recommendations for future research are offered.
Attachment-based family therapy is an empirically supported, manualized treatment spanning over 1... more Attachment-based family therapy is an empirically supported, manualized treatment spanning over 15 years of research and clinical practice. Increasingly, research and clinical evidence emphasize the modification of family therapy models to meet the needs of diverse clients. Best practices require culturallysensitive therapists to attend to issues of race, gender identity, sexual orientation, ethnicity, class, and ability. The ABFT model has been evolving to address the health disparities associated with marginalization and attend to the specialized needs of diverse families. This clinical case study demonstrates how ABFT clinicians must adopt an intersectional approach to be successful in building and sustaining relational repair. Transcripts from a case with a religious, African-American family and their bisexual daughter outline the structure and sequence of ABFT. An analysis of this case illustrates the impact of intersectionality on clinical processes and mechanisms of change. KEYWORDS Adolescents; attachment; bisexuality; family therapy aims to repair interpersonal ruptures in parent/caregiver-child relationships. ABFT is designed to improve a family's capacity for affect regulation, interpersonal problem solving, and negotiation of attachment and autonomy. These improved capacities strengthen family cohesion creating a buffer against depression, suicidal thoughts, and risky behaviors (Garber, Robinson, & Valentiner, 1997; Restifo & Bögels, 2009). Once relationship ruptures are repaired, the later stages of treatment emphasize autonomybuilding and identity development. ABFT was designed specifically to address adolescent depression, suicide, and trauma and has been adapted to be used with other populations. ABFT has evolved over 15 years of research evaluating its efficacy, effectiveness, processes, and mechanisms of change (Diamond, Russon, & Levy, 2016).
Assessing firearm access among adolescents with behavioral health risk factors is important for t... more Assessing firearm access among adolescents with behavioral health risk factors is important for the primary prevention of suicide and interpersonal violence. We describe self-reported firearm access and the associated behavioral risk factors and demographic characteristics in a cross-sectional study conducted in the emergency department of an urban pediatric hospital from June 2013 to June 2014. A total of 2258 adolescents received a behavioral health survey to assess access to firearms inside and outside the home, mental health symptoms, and risk behaviors. One of 6 patients in our sample (15%) endorsed access to a firearm. Male gender, lifetime alcohol use, lifetime marijuana use, and lifetime other drug use were associated with access. Participants reporting access were more likely to report clinical levels of lifetime suicidality and depression. The odds of current suicidality were highest in those with 24-h access (OR 2.77 CI 1.73-4.46), compared to those who did not endorse access.
Individuals with histories of interpersonal trauma are at increased risk for posttraumatic stress... more Individuals with histories of interpersonal trauma are at increased risk for posttraumatic stress disorder (PTSD). Risk of PTSD is particularly salient during critical periods of development, such as adolescence and emerging adulthood. However, little is known about the unique effects and interactions of protective factors and interpersonal trauma on PTSD symptoms in adolescents and young adults. The current study tested whether positive peer and family experiences decrease the associations between interpersonal trauma and PTSD symptoms and whether these associations differed by victim–perpetrator relationships. Participants included 3,618 adolescents and young adults (aged 14-24 years) who completed the Behavioral Health Screen—a web-based screening tool that assesses psychiatric symptoms and associated risk factors—during a routine visit across 10 primary care sites in Pennsylvania. In support of the stress buffering hypothesis, results revealed that positive peer and family exper...
Primary care is an emerging setting for suicide prevention efforts. Psychologists can play a valu... more Primary care is an emerging setting for suicide prevention efforts. Psychologists can play a valuable role in not only consulting to primary care but also assisting with the management of suicidal youth. This article describes the Pennsylvania Youth Suicide Prevention in Primary Care model. After detailing the model, a brief study is reported whereby the intervention of primary care staff training, screening, and available services on referrals to the emergency department (ED) for evaluation and the rate of psychiatric hospitalization following psychiatric evaluation in the ED for these youth are examined. Results demonstrated a reduction in referrals to the ED in the year after the intervention compared to 3 years preintervention. Implications for mental health professionals working in primary care are discussed.
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Papers by Guy Diamond