Guy S. Diamond Ph.D. - Guest
Guy S. Diamond is a Professor Emeritus at the University of Pennsylvania Perelman School of Medicine and Associate Professor at Drexel University in the College of Nursing and Health Professions. At Drexel, he is the Director of the Center for Family Intervention Science (CFIS) and the Director of the Ph.D. program in the Department of Couple and Family Therapy. He has received several federal, state and foundation grants to develop and test this model. Dr. Diamond is the author, with his co-authors, Drs. Gary Diamond and Suzanne Levy, of the book, Attachment-Based Family Therapy for Depressed Adolescents, and continues to develop and implement the ABFT model. |
W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Sutton: (00:22)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for The Advancement of Psychotherapy. Today, I'll be interviewing Guy Diamond, PhD., who's professor emeritus at the University of Pennsylvania School of Medicine, and associate professor at Drexel University in the College of Nursing and Health Professionals. At Drexel, he's the director of The Center for Family Intervention Sciences and the director of the Ph.D. program in The Department of Couples and Family Therapy. He's received several federal state and foundation grants to develop and test his model. Dr. Diamond is the author with his co-authors, doctors Gary Diamond and Suzanne Levy of the book Attachment-Based Family Therapy for Depressed Adolescents, and he continues to develop and implement the ABFT model. Let's listen to the interview. Welcome, Guy! Thanks so much for taking the time to be with us today.
Dr. Diamond: (01:25)
Yeah, I'm honored to be here.
Dr. Sutton: (01:28)
So I've been a big fan since I read one of your articles. Gosh, it must have been in, I think 2005 or 2006. When I was in grad school and had taken a number of your trainings in attachment-based family therapy, we brought you out to do a training on adolescents and suicide. And I was wondering if you could talk a little bit about your work and learn about ABFT because I don't know how many people out there are familiar with it.
Dr. Diamond: (01:57)
Let me give you a little, maybe the historical context of the evolution of the ideas and just to put one frame around it, you know. I was pretty lucky in my training days to work with two sorts of giants in our field. I got to work with Guillermo Bernal who was one of the few contextual family therapists for those that remember Ivan Nagy. I got to work on a research study of his doing contextual couples therapy with heroin addicts in a methadone clinic.
Dr. Diamond: (02:43)
And it was the first for me, the blurring, the integration of research and clinical work, and the excitement of doing those together.
Dr. Sutton: (02:54)
Can you comment on contextual family therapy and what that is?
Dr. Diamond: (02:59)
Yeah, so contextual family therapy, Ivan Nagy, certainly one of the known names, if you're in an intro masters program, you're gonna have a chapter on him. The thing that I thought was beautiful about his work is he really kind of had a language for family therapy that I thought was more compelling than structural work or strategic, even narrative work. In the early days where, you know, the language of the behavior of general systems theory, or cybernetics, nobody would say anything like that in a room. You know, “your feedback loop really seems to be interacting!” For him, the whole therapy was about trust, about, “is this a trustworthy relationship?” And “what's gotten in the way of it being that way?” And for Ivan, there was a lot of intergenerational, he was one of the staunch intergenerational people, what legacies are coming down? What invisible loyalties do I have?
Dr. Diamond: (04:12)
A family of origin that's getting in the way of you know, my current relationships. So I really just love the texture, the language, and the vocabulary of the work, and it had a big impact on me and kind of stuck. So when I moved, I then moved to work with Howard Little in his early days of structural family therapy and we were doing a lot of work with adolescent substance use. And we found ourselves stumbling into these episodes where people are fighting and arguing, and then you'd sort of just scratch your head and step back and say, “I don't get it.” You know, we're talking about homework assignments or cleaning your room, and yet it feels like World War II in here.
Dr. Diamond: (05:15)
“What's this anger really about, if you had to say?” And that was the beginning of my sort of trying to think more about more relational trauma, more relational betrayal. Things that really made people lose trust in each other, made kids feel like I'm really unloved, uncared for. And for me, you know, Ivan's work helped with that. And then my growing interest in attachment theory just completely gave me a language for describing what that looked like. And really a lot was because of my work with Howard. I owe my career to him. Hats off to Howard Little, if any of you know him. And mentorship in general, I really value the whole concept of mentorship. I really benefited from it.
Dr. Sutton: (06:16)
Howard was the developer of multidimensional family therapy and attachment-based treatment for adolescents and substances.
Dr. Diamond: (06:22)
Yeah. Which really came out of the structural strategic sort of tradition and held all those similar values. And Howard, like my own work, you know, he didn't look at Minuchin's work around boundaries and hierarchy, but he did look at it in terms of enactment and session change. And you know, Minuchin once said about narrative therapy. He said, “where's the family therapy in narrative therapy? There's no turning to each other and talking about something. It was much more of a kind of cognitive sort of process, in its theory anyway.” So working with Howard was great. He was just brilliant. The hours behind the one-way mirror, where we just thought about the moves of therapy. How did he say that? What could he have done? And should he have done it? Should he move closer? No? Why? He's not taking care of the mom enough.
Dr. Sutton: (07:27)
And it just gave me an appreciation of the subtleties of therapy. What I started to think about when I got to the Philadelphia Child Guidance Center, I was lucky enough to do my internship there for my Ph.D., was how to make these good sessions happen more often.
Dr. Diamond: (07:48)
Rather than stumbling into, “oh, I just had the best session ever and, you know, they really cried and got to the heart of the matter.” I sort of thought, is there a way we could plan for that, prepare for that, build towards that, so it happens intentionally rather than luckily stumbling into it. And that was really the beginning of ABFT, the sort of in some ways dismantling of some core mechanisms of family therapy in general. You know the reframe, we all do the reframe. We're all trying to engage people into a more relational view of therapy rather than fix my kid. So we started to think,” well, how do we do that? And how do we accomplish it? and what are really the steps?” And then for us, we split people up and said, “you know, look. So the kid, you have legitimate complaints, but you don't articulate them well.
Dr. Diamond: (08:49)
You're a little emotionally dysregulated. You don't feel entitled. And we wanna help you have a more clear narrative of your felt injustice.” And then meeting alone with the parents. We sort of figured out when we get into these conjoint sessions and we want our parents to listen better. We want them to pay attention and heal these wounds, these ruptures, and sometimes apologize. And we just found we needed more preparation work, you know, in Minuchin's work, he was so charismatic. He could say, “turn to your son and do this thing.” And they would do it because Minuchin's telling you to do it, you know? But most of us are not Minuchin. So we started to think a lot about how you soften the parent, get them to feel more, access more empathy, and be more emotion-focused in their parenting. How to help them slow down from problem-solving. And then we thought about how we bring them back together, what do we wanna accomplish? And from an attachment point of view, we are trying to create a corrective attachment experience where kids feel like; you weren't there for me, you don't love me, you love my brother more, or you were an alcoholic, or mom and dad fought. Whatever variety of reasons got in the way of parental attention.
Dr. Sutton: (10:29)
Or you were too involved and too intrusive and too controlling. We know, simplistically, those two patterns exist in all our cases, some variation of it. And we wanted to see if kids could negotiate their way into a better relationship, which from an attachment point of view is exactly that. I'm tied up in my insecure attachment knot, I’m defensive. And we wanted to try to untie the knot and say, “Hey, I'm hurting. I feel bad. This is why.” And we wanted our parents to say, “oh my God, I'm so sorry. Things were tough. I shouldn't have been that way.”
Dr. Sutton: (11:17)
Engage that attachment part of them to suit their child.
Dr. Diamond: (11:21)
Right, and be able to. Not that it's the whole story. It's just for an adolescent they're so burning to be heard and understood. And until you validate some of their resentment and animosity perspectives, it's for them to wanna cooperate. In that case, we often talk about that. It just exemplifies this as the alcoholic parent who goes away to drug treatment. Come home two years later, 18 months later, all cleaned up and like, “I'm ready to be your parent again.” You know, the kids like, “who are you kidding? Why did you ruin my life? You've been gone. Why would I let you walk in and tell me to go to bed at eight o'clock?”
Dr. Diamond: (12:15)
So, it's very clear in that case that until the kid can talk about his hurt and rejection, and anger, the parents are never gonna be able to resume the role of parental guidance authority. And so that's how we sell it to parents, let your kid get the stuff off his chest. And we think he'll be a little more cooperative
Dr. Diamond: (12:43)
And then we try to move into task five where it's, you know, it's kind of back to day-to-day behavioral things, but we're trying to help parents position themselves to support and challenge their kid without being overcontrolling or neglectful.
Dr. Diamond: (13:06)
Some classic family therapy things, but trying to think about it from an attachment point of view. How do I provide a secure base and autonomy, but don't abandon you or don't overcontrol you? And again, just kind of use an attachment frame to kind of guide what we do. So we dismantle family therapy into these kinds of core components and play to them and have tried to think about the different challenges in each of these stages and some structure and guidance. And I think young therapists find, “oh my God, this is a scaffold that allows me to do profound therapy long before I thought I could. I thought I had to be Keith to do work.”
Dr. Sutton: (13:56)
That kinda gives some of those steps or that kind of direction of what to do next. Kinda pieces that oftentimes begin with family therapists.
Dr. Diamond: (14:07)
Just don't, you know, don't have the confidence. And so it's actually a twofold thing. And the last thing I'll say, on the one hand, we've given enough structure on the other hand. It's kind of the way we think about it is more in the EFT emotion focus, process-oriented world
Dr. Diamond: (14:29)
And that requires a lot of just savvy and self of the therapist and the ability to track the deep process in the room. And we're trying to teach therapists that as well, I think, and the model has both structure and depth to it.
Dr. Sutton: (14:50)
I think that process orientation takes some time to help shift our thinking to where I was in my experience and I'm a certified focused therapy supervisor, but that process orientation and kind of not getting caught as much in the content I think is so important. So it sounds like you're influenced by the work you're doing with Ivan and particularly his trust piece that you were talking about seems to, you know, when I think of attachment, I often think of trust and safety. And so that makes sense. And you were kind of having those incredible sessions you were getting with ABFT. You kind of were trying to then figure out, like, “how do I help create the steps to have that happen more in an intentional way?” And that kind of helping the kids really talk about their pain and really helping the parents to hear it and take it in helped to reconnect them and then made a lot of the other stuff easier. Some of the, you know, the hard side of the hybrid kinda rules, consequences, you know?
Dr. Diamond: (15:59)
Yeah. It helps kids talk, and accept their attachment needs again.
Dr. Diamond: (16:06)
So I really do love my mom. I really do want her around. And if she's willing to be there for me more, or give me more space then I'd like to have her on my team.
Dr. Sutton: (16:18)
Yeah.
Dr. Diamond: (16:18)
So that's because adolescents do actually want to talk to their parents and have a connection. Their parents often think, “oh, they're teenagers and they don't.”
Dr. Sutton: (16:31)
So tell me a little bit about that too. I mean, you've done a bunch of research on this. I know that you've also applied this to different issues and you know, I think I forget exactly. Is it listed as evidence-based or what's the kinda listing for it?
Dr. Diamond: (16:45)
Yeah, when I was working I think one of my bigger commitments, professional commitments, has been to try to keep family therapy on the map of modern healthcare. And I think, although I love the therapy part and love the art artistry of it. I sort of got socialized by my two mentors, both Howard and Guillermo who were researchers to say, if we don't as a field, get some evidence going, you know, we're just gonna be left behind in the insurance panels and do we get taught in schools or not? And I mean, in Europe, this is deeply ingrained. If you're not on the panel in Sweden they don't pay for it.
Dr. Diamond: (17:47)
You know, so it's never quite come to that here, but I think family therapy struggles here. In a lot of places, I know they still struggle to get reimbursed for family therapy. They can't see parents alone for child therapy. They won't pay for a parent-alone session even though it's in the service of moving the kid forward. So, I think I've always had a value set of let's keep showing these works. Let's do research and it was a tall mountain to climb. Everyone thinks, “oh, let's do a little research.”
Dr. Sutton: (18:31)
Yeah.
Dr. Diamond: (18:32)
You know, it's a long, hard climb, and getting funding is a long, hard climb, and then publishing the data, doing a study. We just finished one study, took two years to get the grant funded, you know, you're right and it gets rejected. You write it again, you know, it took six years to collect the data.
Dr. Diamond: (18:56)
And then a year after that to write at least the main outcome paper, so seven years.
Dr. Sutton: (19:02)
Wow. It's a lot of work throughout.
Dr. Diamond: (19:05)
For one study and every day of that study, it's not like, “oh, okay, go ahead and go.” Every day of that study it was “Can we recruit, are these cases working? Are we getting it? Will they do it”
Dr. Diamond: (19:22)
It's a lot of work.
Dr. Sutton: (19:24)
And a lot of the funding has predominantly, I think, tell me if I'm right wrong here, go to like substance abuse treatment. I know there are a number of different evidence-based models for adolescents and substance abuse. But one of the things I like about your model too is it's one of the only models that focus on an internalizing disorder such as depression. And I think the first research you did was on kids that had made a suicide attempt, is that right?
Dr. Diamond: (19:51)
We actually started with depression. I was in an inpatient unit and it was all around, you know, every kid that got admitted. So we kind of got our first grant, our first NIMH grant around depression. But at the time this was the sort of mid-nineties, and the suicide field was still tremendously underdeveloped.
Dr. Diamond: (20:18)
Even in the funding in most studies, they would reject the kids that were suicidal. Like people would say, “oh, that's too difficult, high risk. Let's not put them in our studies.” So there was really a big push in the late nineties to start funding suicide research. So we, you know, started adapting some of the work to that. And it's really the center of my identity. Now I'm really both a prevention and treatment person. But the interesting thing about suicide is, you know, for us family therapists it's just a symptom. It's the warning flag that something's amiss. But you're working with kids with trauma. You're working with LGBTQ kids who are being bullied. You're working with kids with anxiety disorder. You're working with kids with, I mean, it's quite a comorbid population not isolated. So I think a lot of what we learned was how to work with a lot of, as you're saying a lot of internalizing kids. Now there are a lot of family interventions.
Dr. Diamond: (21:35)
Not many of them have done enough work to become classified as empirically supported. We are and we've done enough studies and we're on the SAMSA, what used to be the N-reps website. So we climbed the mountain and now we're considered. You know, what are the treatments for adolescent depression and suicide? Along with CBT and medication, and now DBT, a family therapy model is on the list. And with that, I feel some pride about that.
Dr. Sutton: (22:12)
It's good.
Dr. Diamond: (22:13)
Sustained a role in the field.
Dr. Sutton: (22:18)
And I think you've applied this also to some other issues too. I remember talking one time maybe to self-harming and maybe to gay, lesbian, or bisexual teens. Can you talk a little bit about that?
Dr. Diamond: (22:36)
Yeah, so probably our most systematic adaptation we'll call it, you know, kind of moving to another distinct enough population. That's different enough from our regular depressed kids who have really been in the LGBTQ arena.
Dr. Diamond: (23:01)
My colleagues, Gary Diamond now in Israel, and Jody Russon now at Virginia Tech have really kind of systematically moved the work forward. Gary particularly has done studies on the LGBTQ with the gay and lesbian adult population. And Jody's really picked up the trans kids, she's in more systematic work in that population. The exciting thing about Gary's work also has been that he has done more work with adults, young adults, and teenagers.
Dr. Diamond: (23:41)
So a lot of his patients are 27-29 all in Israel. And so it's been some very exciting work about family therapy with older kids who are living on their own, maybe married.
Dr. Diamond: (23:56)
Bring in grandparents, parents, you know, into a therapy process for some short-term structured trauma work, if you will. I've really loved that adaptation so that's been our biggest dramatic adaptation and we have published the most in that area and adopted adaptations to that.
Dr. Sutton: (24:26)
Yeah. I think sometimes people forget that you can do family therapy with adult children if the parents are alive. I actually used principles of attachment-based family therapy with a mom in her late eighties and a son in his late sixties the mother had also immigrated from China
Dr. Diamond: (24:55)
Oh, wow.
Dr. Sutton: (24:56)
It's just, you know, the model was really helpful to them. It was just helpful in repairing, you know, some of the distance that they had and really kind of strengthening that connection even this far past.
Dr. Diamond: (25:16)
I mean, the way I often say it in my, when we do trainings is for those of you doing adult individual psychotherapy, probably 40% of the time, you're still talking about their parents. What did they do or didn't do? She loved me. She didn't love me. And I think you can use the ABFT technology, if you will, to invite that parent in and say, “look, let's try to address some of these old hurts and you know, why spend the last 20 years of mom's life resenting her and why not sit down, have it out and see if we can't make these last few years together beneficial and hopeful.
Dr. Diamond: (26:09)
And I think the ABFT model allows you to plan for that in a way that increases the likelihood of it working.
Dr. Sutton: (26:13)
Exactly, sometimes I talk to some clients when it seems like that would be very helpful or like, you know, let's at least give it a shot, maybe hopeless, and it's not gonna change. But you know what, at least you can feel like I tried and when the parent passes away you know that you did all that you could.
Dr. Diamond: (26:29)
Yeah, right.
Dr. Diamond: (26:33)
And, I think the way we've broken it up, you know, that if we would meet alone with the parents first we would get to know them and understand their needs. And, you know, there's a lot of preparation so that when we bring them together, nobody's feeling like they're getting thrown under the bus.
Dr. Sutton: (26:50)
Yeah, I mean, what you're speaking to is what I love about systems work, you know, because I on an individual level do CBT and EMDR. But then oftentimes, well then I bring in a partner, you know, kinda access some of those core beliefs. Then bringing the parent to actually work on some of those traumatic events where the core belief actually started.
Dr. Sutton: (27:16)
You know, even a client of mine who was in his early thirties, we did some good EMDR around trauma and you have these questions like, why have parents reacted this way during that time? So we got them on the laptop and, you know, had a talk with them. And the mother said, “oh my gosh. I feel so bad. You've been thinking, I thought it was your fault, you know when you were seven.” So yeah, such a nice shift that, you know, we can do with the parents rather than necessarily spending years kind of doing it through our relationship.
Dr. Diamond: (27:48)
Yeah, kind of accelerates that work. How did that impact the EMDR work afterward?
Dr. Sutton: (27:57)
It was very helpful. I mean, he had an experience of molestation by a babysitter when he was young. The parents, you know, intervened and he got the impression that he was in trouble and that stuck. And so when he actually got that from his mother saying, “my gosh, it was not, that was not you at all. That was not your fault. I kind of separated you and so on to kind of find out what was going on and such yeah.” And further, in the EMDR, he was able to shift some of that toxic chain and I've really gotten into more of the complex trauma lately.
Dr. Diamond: (28:34)
That's just great. You know, we're working with Newport Residential Facility.
Dr. Sutton: (28:43)
Yeah, Newport Academy.
Dr. Diamond: (28:44)
Their staff is cross-trained, they're doing ABFT, and a lot of them now have learned EMDR. And I'm really kind of excited about the interface of those two modalities and how because so many of our kids and so many of our parents are stuck in trauma and we can't get them to move because of it.
Dr. Sutton: (29:03)
Yeah.
Dr. Diamond: (29:03)
We're trying to figure out from the other side how to integrate it into the family therapy work so that it could facilitate that. So that's a really exciting area to be in.
Dr. Sutton: (29:19)
And I've used it with even a teenager and the family. The attachment sessions are going really well, you know, actually helping make a significant shift as a teenager whose father reacted and pulled out the belt years earlier. It didn't actually hurt, but that changed their relationship and the dad was kind of more of a shut-down guy. He had immigrated from Chili and he was kinda emotionless then broke into tears and said, you know, “I never wanted you to have that experience” that he had as a child. But the child still had some of that emotional reactivity so we did some EMDR around that and then another ABFT session.
Dr. Diamond: (30:03)
Interesting.
Dr. Diamond: (30:06)
We often find exactly that but let's be humble. Sometimes family therapy is just not enough. It's good stuff. And the sessions you're talking about, who wouldn't wanna be doing those? But we're always referring to the kid afterward to fix the residues of these traumas and the emotional reactivity. And so trying to think multimodal, I think it is really a direction family therapy should be thinking. I think that CBT work, they've taken off, you know, and in the CBT and DBT studies around suicide and depression. it's all multimodal, they're not, you know, they call it DBT, but it's family group, support group, family therapy, and Group therapy,
Dr. Sutton: (31:04)
And actually, you know, speaking of DBT and actually self-harm. Had you done a research study on self-harm non-suicidal self-injury with adolescents on campus?
Dr. Diamond: (31:15)
You know, we've never done that as the primary problem, 30-40% of the kids in our last study reported self-harm. So we know as their depression goes down and there, you know, self-harm goes down as well. So it's definitely a sort of byproduct. I think you're right though, maybe it is what you're thinking. The cutting it's such self-regulating energy for their emotional intensity.
Dr. Diamond: (31:51)
And the question becomes is the emotion regulation experience in family therapy enough to internalize some new skills or do you also need to be doing some DBT and meditation work around that or also doing some EMDR?
Dr. Sutton: (32:13)
I was gonna say, you know, the way I think about it too is that I ask the kids, “when you feel like hurting yourself, whether that be suicidal or self-harm, can you turn to your parent, and if not, why not.” Because you think, oftentimes when you can reconnect that attachment, then they're able to turn with their pain and ultimately get what they hadn't been getting, which is that co-regulation which internalized. So definitely adding mindfulness and you know, the DBT I think are all really good to have those additional skills. But to actually have that, you know, ability to kinda connect attachment in for support, I think it helps with the regulation. Internalizing the ability to self-soothe. We were also working with parents and helping them learn how to stay regulated.
Dr. Diamond: (33:06)
That's what I was gonna say. I think our, you know, in our next study, what we'd like to do is intensify the parent part of the treatment.
Dr. Sutton: (33:16)
Yeah.
Dr. Diamond: (33:17)
Because for so many of our kids the parents just are as dysregulated as the kid.
Dr. Sutton: (33:23)
Yeah.
Dr. Diamond: (33:23)
And to try to teach them some self-management skills, some self-soothing skills we hope that improve their parenting. Giving them an experience of competent parenting helps them internalize a new sort of narrative or image of themselves. “Oh, I can be a good parent and this can work. I don't have to slam the hammer on them, I can just talk.” But not unlike the kid, it just sometimes isn't quite enough, you know?
Dr. Sutton: (33:56)
Yeah, definitely.
Dr. Diamond: (33:58)
Let's do 12 weeks of EMDR with our parents as a prerequisite
Dr. Sutton: (34:03)
Disarming some of those triggers that are hard for them to stay present. But some of the parents I work with, that I talk about, it's like, “we wanna be that rock in the ocean that the waves are crashing up against, rather than that kinda rowboat just kind of getting tossed.”
Dr. Diamond: (34:18)
Right.
Dr. Sutton: (34:20)
And helping them to be able, kinda do that.
Dr. Diamond: (34:22)
Well, I would like to do more of that.
Dr. Sutton: (34:24)
Yeah.
Dr. Sutton: (34:26)
Tell me about the eating disorder work that you're doing research on.
Dr. Diamond: (34:31)
Yeah. So we've been really, you know, fortunate in the eating world, the FBT world, the Maudsley world.
Dr. Sutton: (34:41)
That family-based therapy for anorexia.
Dr. Diamond: (34:43)
Yeah. Which really comes out of the old Munchkin strategic tradition and, you know, they themselves have gone through a little bit of self-examination, whether we are too behavioral.
Dr. Diamond: (35:02)
Really the essence of that model is parental control and we're gonna make our kid eat. And they sometimes feel like, “whoa, we're up against such resentment here that we just, you know, we need to do something a little different for a while.” And so a lot of FBT people have turned to us as a model for a kind of a pathway of, “oh, when I need to do more interpersonal work FBT can guide me in it.”
Dr. Diamond: (35:36)
We've actually done a lot of work with the Maudsley team in England and Ivan. And, you know, he was a giant when I was growing up and now he's calling me over Guy and come teach my staff, do this work. And, you know, he has just been a great collaboration, but there are two ways they're using us. One when the anorexia cases are just up against so much resistance, it's sort of like, well, let's change gears here. Let's figure out why you're so resistant to your mom taking care of you. Let's get why you don't go to your mom for help. And the other big area they are using is bulimia cases, they tend to look a little bit more like depression cases, with more chaos, more family conflict, and more emotional disruption.
Dr. Sutton: (36:36)
Just regulation.
Dr. Diamond: (36:37)
So there's a lot of interest and there's been remarkably little research in the area of family therapy and the FBT study.
Dr. Sutton: (36:44)
Yeah.
Dr. Diamond: (36:45)
So we've been supporting Maudsley and doing it. They have a pilot project going on and we've started our own pilot study. We're about to finish our first 10 cases too, you know, work with bulimic cases. And for the most, you know, the model fits pretty well. We're doing this in a collaboration with CBT.
Dr. Diamond: (37:17)
You know, it's really a lot more about how do we integrate these when kids are purging five times a week, you can't just sit around talking about your feelings. You got to do something concrete to manage that, but they're missing something and we have felt we need something. So we're partnering up and that's nice to learn how to pace those two sequences and how to do more behavioral management, but also do it from a more attachment kind of frame.
Dr. Sutton: (37:51)
Yeah.
Dr. Diamond: (37:52)
So far it's gone pretty well. There are a couple of cases that are hard, but yeah. Always get those.
Dr. Sutton: (37:59)
Yeah. I actually get some training with care. Down at Stanford, we had, I always forget. And she did actually a training for us and then a 10-week, one-way mirror series, which was really great. And I really like the model in that it really focuses on a structural model essentially of helping kind of parents to access their kind of instincts to take care of the children. And I think anorexia particularly because, you know, the kids almost become phobic of eating, you know, and get so reactive that sometimes it's so overwhelming for the parents. And again, they end up seeing it as an attack sometimes rather than care. So definitely makes it understandable how the based work would be helpful in potential against anorexia.
Dr. Diamond: (38:55)
And it's actually interesting that this group is the first one I saw. They did a comparison between the FBT and a General Family Therapy Model, just kind of general and both models worked well in the outcome research.
Dr. Diamond: (39:13)
So, I think it was a little crack in like maybe this kind of behavioral control isn't the only mechanism that these families need. And maybe there is some sort of just relational connection. Better communication and more emotional containment help the FBT world try to think a little more broadly.
Dr. Sutton: (39:34)
Yeah.
Dr. Sutton: (39:39)
Yeah, I think that's a tough place. And especially, I know in their first stage of their work of the kind of the repeat that it's like, you know, this kid is gonna die and yeah. But it ends up yet hitting up against that so hard. And is there any way to kind of help that go sooner or so on? You know, there was one part you were mentioning earlier about, you know, part of the attachment session is kind of helping create that corrective experience. And I think that you know, that piece, I think is so important. Because I think oftentimes in individual therapy, that's really a big piece of goal or at least, you know, particularly from a dynamic perspective of having that different relationship and the transference countertransference and control mastery. Not fulfilling those roles, the person is able to have a different experience. And yeah, I just wanna get, I guess your thoughts on that piece and so on. I mean the way again, I conceptualize it, I think that's always great. And the measure of the relationship with the therapist is essential, I want them to actually have the corrective experience with their attacking figure the whole rest of the week and, and so on.
Dr. Diamond: (41:08)
I mean, I think there's a number just to frame that answer like this there's a number of individual therapies that have adopted a kind of an attachment framework schema. Therapy does, you know, there's a number of other people and in some ways, I always say we're all doing the same work.
Dr. Diamond: (41:40)
You know, we're trying to be a secure enough base so these kids can develop a more coherent view of themselves and their history, And by coherent, I mean, not only be able to articulate it more honestly but feel the feelings that come with it.
Dr. Sutton: (42:03)
Yeah.
Dr. Diamond: (42:03)
Between the hurt, and the disappointment and not feeling like I gotta push that side away and just come up with some story that helps me explain. But it's like, I can be honest about how bad it was, feel legitimate to talk about it. And I can rather repress or contain these feelings, which leads to emotional dysregulation because I'm spending energy hiding from vulnerable emotions. I mean, this is an EFT kind of principle. I'm gonna be able to integrate those feelings more. And I think individual work can do a lot of that.
Dr. Diamond: (42:45)
And all of us are good parents to our patients and try to recreate an experience of trust and safety for them. So they can do some internal reflecting work.
Dr. Diamond: (43:04)
You know, whether there's something accelerated, if the actual parent comes in the room and says, you know, “I'm sorry, or shouldn't have been that way or tell me more.” We think there's existentially something that gets accelerated, more profound.
Dr. Sutton: (43:23)
Yeah.
Dr. Diamond: (43:24)
In Gary Diamond’s study, he compared enactment, that's task four of ABFT, bringing the parent in, getting everybody ready, and then getting off your chest and parents listening. And, oh my God, I didn't believe it. And he randomized some patients and other patients got the two-chair technique.
Dr. Diamond: (43:53)
And the question was if you do this imaginary, is it relatively better to do it in reality, the real relationship versus just thinking through and what would I say to my mom?
Dr. Sutton: (44:10)
Yeah.
Dr. Diamond: (44:11)
And the study basically found both treatments worked well in reducing anxiety and depression. We know EFTs are powerful and the ABFT works, but the patients reported improved perceived attachment with their parents as a result of the real. So it had a more sustained relationship impact. Whereas the imaginable work helped me change my internal view of myself, it didn't change my real relationship,
Dr. Sutton: (44:44)
Relationship and reality.
Dr. Diamond: (44:46)
So it's, you know, an interesting way, different.
Dr. Sutton: (44:51)
You know, one of the cores of systemic thinking is that you create more lasting change from that shift in the system to help support the individual change.
Dr. Diamond: (45:02)
Yeah.
Dr. Sutton: (45:03)
I mean the relational part of the connection with the adolescents, particularly in your model. Because I think that, you know, I know that a lot when I'm teaching family therapy or so on with individual clients that maybe are, or therapists that are worried about that. The teenager might not want to talk to the parent or it's gonna ruin the relationship between them if they're bringing the parent into the therapy or working with them together. And some of those concerns around the holding space for the adolescent. Just wondering if you can maybe speak to that because I think that, you know, ultimately you're trying to get them to access their vulnerability.
Dr. Diamond: (45:45)
I mean, I think we think about it in two ways and this is all task two.
Dr. Diamond: (45:53)
You know, when we talk about a task, it's not something that you do. Okay, I'm now doing, you know, it's a set of principles, a set of mechanisms that I'm gonna play out because I'm trying to accomplish something. Because I might be way down the line six months later and say, “oh, I gotta go back to task two and I gotta get a little bit more of this” and you're sort of moving back and forth between. So in that task, we do think about them creating us as a transitional object as the old Winnekot would say “That we create.”
Dr. Diamond: (46:35)
I got a kid right now, actually, my bulimic patient, who's been in a bunch of eating disorder programs that have all been sort of, you gotta change and I've been totally on his side.
Dr. Diamond: (46:57)
Of course, you're angry and of course, you're mad. You should be mad. And he says to me, “I've never felt like a therapist has been on my side before.”
Dr. Diamond: (47:09)
I have always felt they're on my mom's side.
Dr. Diamond: (47:12)
You are the first person that I feel represents me but he didn’t say it like that.
Dr. Sutton: (47:16)
Yeah.
Dr. Diamond: (47:17)
But I think that was a powerful joining. So I think that's one of our mechanisms. We just really side with and empathize with their story. But I think the other mechanism is that we do explicitly ask about their attachment narrative and say, you know, “tell me how bad it was. Tell me how mad you are. Tell me the things your parents do that you felt were so unjust.” And I think in doing that, it primes them to, you know, it helps them articulate that story of injustice that they experience. And it primes them so that when we go, ready to do the family work, that story's been told and they're more comfortable with it. They're willing to acknowledge the hurt that they feel. And, I think those two things together allow us to transition back into family peace,
Dr. Sutton: (48:25)
Like even a mini exposure to kinda get ready.
Dr. Diamond: (48:29)
Exactly, yeah. And it's poignant, you know.
Dr. Sutton: (48:39)
Isn't there a key question in that session with the adolescent, I forget what it was. Something to the effect of like, when did you give up on your parents?
Dr. Diamond: (48:51)
When did you fire them? We sometimes, yeah. Like what's happened to make you so angry at them? You deserve to be angry. You should be angry. It's legitimate, but let's see if we can't describe it a little bit better. So it's not because most of the kids when they start to think about these things, it comes out totally dysregulated. I don't know what it is. I just hate them so much. Do you know? And we want them to say no, no, no. Let me tell you what it is. And let me tell you how I feel and let me cry about it. Let me really know the landscape of that disappointment as a way for them to capture their own sense of self.
Dr. Sutton: (49:43)
One client I was working, he was hospitalized, and I set up those sessions. I told him that next session I'm going to ask you when was the moment you kind of gave up on your parents. And he said, “oh, I don't have to wait. I can tell you right now. It's when I realized I was gay, but I didn't wanna be. And I started smoking pot and they busted me because of pot smoking and they just came down hard on me and they didn't even ask me what was wrong with me. And that's when I realized that I can't go to them.”
Dr. Diamond: (50:16)
Yeah.
Dr. Sutton: (50:17)
His being able to talk to his parents about that really was a key piece because it was kinda the moment that changed their relationship.
Dr. Diamond: (50:26)
Yeah. That's great, and I think a lot of kids have that kind of story.
Dr. Diamond: (50:35)
I mean, some kids it's just so chronic chaos, you know, I'd say 70% of our kids have a story. They don't know how to put it into words. They don't feel like they deserve to put it into words. With our depressed kids, you know, a lot of our depressed kids are actually pretty protective of their parents. You know, they got enough on their plate. Mom already has her own health problems.
Dr. Diamond: (51:07)
So they keep a lot of pain to themselves. I mean it's all kinds of variations.
Dr. Sutton: (51:13)
Yeah.
Dr. Diamond: (51:15)
But I think what you said is exactly right. And I think it's what the model does. It allows you to pinpoint those kinds of questions rather than just, “oh, let's talk about therapy and how you are. what do you mean?” It's like, no, tell me about the betrayal.
Dr. Sutton: (51:32)
Yeah, it's like the surgical kinda going right to that.
Dr. Diamond: (51:35)
Yeah, surgical.
Dr. Sutton: (51:36)
Yeah, actually what you're just saying, reminds me of the story. In one of the trainings, I was in one of the therapists who mostly did individual talk about, you know, thinking of a client of hers where, you know, the individual therapy would be the best. And then the trainer asked, “And why do you think that what's the client therefor or not?” The individual therapist was talking about, you know, having a place for the girl to talk and the therapist asked, “oh, and does she talk to her mom?” She said, “no, she doesn't wanna burden her because her mom has cancer.”
Dr. Diamond: (52:08)
Yeah.
Dr. Sutton: (52:09)
And so right there was the answer that this kid was holding everything inside because she didn't want to burden the parent. And actually, the parent wanted to be a parent. And even though the parents had cancer, they still wanted to be able to take care of their dog.
Dr. Diamond: (52:26)
You know, in these less insidious cases, I remember a case where a mom was dying of cancer and everyone knew, but the mom didn't wanna upset anybody. So she didn't ever want to talk about it.
Dr. Diamond: (52:45)
And we just really helped her see that you know, not talking about it is just eating them up. And you know, so our task four was mom coming and saying, “look, you know, how are you handling this? What's this like for you?”
Dr. Sutton: (53:04)
Yeah.
Dr. Diamond: (53:05)
Girl, you know, just falling apart, holding back all this pain. But it was about, and I think a lot of the ABFT is that it's not always these hostile chronic things. Can we talk about the things that are difficult? Divorce is a classic one. How many cases have you had where the parents got divorced? It's messy as hell, but we never talk to the kids about it. Oh, he's eight. He doesn't know. And the kids are totally torn up and confused and like, you know, maybe we should contain them and hold them.
Dr. Sutton: (53:43)
Yeah, with the Jim Kinds model, the one that I work with in the Jim clinic. Particularly he, you know, often talks about that, to have that parental hierarchy that parents need to be able to handle the hottest topics. That means talking about the trauma, talking about, you know questioning sexual orientation, talking about the divorce. And until those conversations can really be had, the kids can't necessarily feel that sense of trust in putting them into the parents' hands and trusting that the parents can handle things.
Dr. Diamond: (54:17)
That's great. That's exactly why I love that we use hot topics.
Dr. Diamond: (54:25)
One to engage the kid, because this is what's important to them. And two to have a sort of exposure experience of talking about a hot topic and not dying because of it.
Dr. Sutton: (54:38)
Yeah, exactly.
Dr. Diamond: (54:39)
We finally talked about it and my head didn't blow up, you know? I didn't have a heart attack.
Dr. Sutton: (54:45)
And the therapist can help it go well.
Dr. Diamond: (54:49)
Yeah, but I love that.
Dr. Sutton: (54:51)
So thank you so much for taking the time today. This is really great. And it's always good to talk with you about, you know, putting these ideas together and so on to get ABFT out there and more people learning about it.
Dr. Diamond: (55:06)
Yeah, I love it. I always love talking to you about therapy. You have a great mind for kindred souls.
Dr. Sutton: (55:14)
I know, right?
Dr. Sutton: (55:26)
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for The Advancement of Psychotherapy. Today, I'll be interviewing Guy Diamond, PhD., who's professor emeritus at the University of Pennsylvania School of Medicine, and associate professor at Drexel University in the College of Nursing and Health Professionals. At Drexel, he's the director of The Center for Family Intervention Sciences and the director of the Ph.D. program in The Department of Couples and Family Therapy. He's received several federal state and foundation grants to develop and test his model. Dr. Diamond is the author with his co-authors, doctors Gary Diamond and Suzanne Levy of the book Attachment-Based Family Therapy for Depressed Adolescents, and he continues to develop and implement the ABFT model. Let's listen to the interview. Welcome, Guy! Thanks so much for taking the time to be with us today.
Dr. Diamond: (01:25)
Yeah, I'm honored to be here.
Dr. Sutton: (01:28)
So I've been a big fan since I read one of your articles. Gosh, it must have been in, I think 2005 or 2006. When I was in grad school and had taken a number of your trainings in attachment-based family therapy, we brought you out to do a training on adolescents and suicide. And I was wondering if you could talk a little bit about your work and learn about ABFT because I don't know how many people out there are familiar with it.
Dr. Diamond: (01:57)
Let me give you a little, maybe the historical context of the evolution of the ideas and just to put one frame around it, you know. I was pretty lucky in my training days to work with two sorts of giants in our field. I got to work with Guillermo Bernal who was one of the few contextual family therapists for those that remember Ivan Nagy. I got to work on a research study of his doing contextual couples therapy with heroin addicts in a methadone clinic.
Dr. Diamond: (02:43)
And it was the first for me, the blurring, the integration of research and clinical work, and the excitement of doing those together.
Dr. Sutton: (02:54)
Can you comment on contextual family therapy and what that is?
Dr. Diamond: (02:59)
Yeah, so contextual family therapy, Ivan Nagy, certainly one of the known names, if you're in an intro masters program, you're gonna have a chapter on him. The thing that I thought was beautiful about his work is he really kind of had a language for family therapy that I thought was more compelling than structural work or strategic, even narrative work. In the early days where, you know, the language of the behavior of general systems theory, or cybernetics, nobody would say anything like that in a room. You know, “your feedback loop really seems to be interacting!” For him, the whole therapy was about trust, about, “is this a trustworthy relationship?” And “what's gotten in the way of it being that way?” And for Ivan, there was a lot of intergenerational, he was one of the staunch intergenerational people, what legacies are coming down? What invisible loyalties do I have?
Dr. Diamond: (04:12)
A family of origin that's getting in the way of you know, my current relationships. So I really just love the texture, the language, and the vocabulary of the work, and it had a big impact on me and kind of stuck. So when I moved, I then moved to work with Howard Little in his early days of structural family therapy and we were doing a lot of work with adolescent substance use. And we found ourselves stumbling into these episodes where people are fighting and arguing, and then you'd sort of just scratch your head and step back and say, “I don't get it.” You know, we're talking about homework assignments or cleaning your room, and yet it feels like World War II in here.
Dr. Diamond: (05:15)
“What's this anger really about, if you had to say?” And that was the beginning of my sort of trying to think more about more relational trauma, more relational betrayal. Things that really made people lose trust in each other, made kids feel like I'm really unloved, uncared for. And for me, you know, Ivan's work helped with that. And then my growing interest in attachment theory just completely gave me a language for describing what that looked like. And really a lot was because of my work with Howard. I owe my career to him. Hats off to Howard Little, if any of you know him. And mentorship in general, I really value the whole concept of mentorship. I really benefited from it.
Dr. Sutton: (06:16)
Howard was the developer of multidimensional family therapy and attachment-based treatment for adolescents and substances.
Dr. Diamond: (06:22)
Yeah. Which really came out of the structural strategic sort of tradition and held all those similar values. And Howard, like my own work, you know, he didn't look at Minuchin's work around boundaries and hierarchy, but he did look at it in terms of enactment and session change. And you know, Minuchin once said about narrative therapy. He said, “where's the family therapy in narrative therapy? There's no turning to each other and talking about something. It was much more of a kind of cognitive sort of process, in its theory anyway.” So working with Howard was great. He was just brilliant. The hours behind the one-way mirror, where we just thought about the moves of therapy. How did he say that? What could he have done? And should he have done it? Should he move closer? No? Why? He's not taking care of the mom enough.
Dr. Sutton: (07:27)
And it just gave me an appreciation of the subtleties of therapy. What I started to think about when I got to the Philadelphia Child Guidance Center, I was lucky enough to do my internship there for my Ph.D., was how to make these good sessions happen more often.
Dr. Diamond: (07:48)
Rather than stumbling into, “oh, I just had the best session ever and, you know, they really cried and got to the heart of the matter.” I sort of thought, is there a way we could plan for that, prepare for that, build towards that, so it happens intentionally rather than luckily stumbling into it. And that was really the beginning of ABFT, the sort of in some ways dismantling of some core mechanisms of family therapy in general. You know the reframe, we all do the reframe. We're all trying to engage people into a more relational view of therapy rather than fix my kid. So we started to think,” well, how do we do that? And how do we accomplish it? and what are really the steps?” And then for us, we split people up and said, “you know, look. So the kid, you have legitimate complaints, but you don't articulate them well.
Dr. Diamond: (08:49)
You're a little emotionally dysregulated. You don't feel entitled. And we wanna help you have a more clear narrative of your felt injustice.” And then meeting alone with the parents. We sort of figured out when we get into these conjoint sessions and we want our parents to listen better. We want them to pay attention and heal these wounds, these ruptures, and sometimes apologize. And we just found we needed more preparation work, you know, in Minuchin's work, he was so charismatic. He could say, “turn to your son and do this thing.” And they would do it because Minuchin's telling you to do it, you know? But most of us are not Minuchin. So we started to think a lot about how you soften the parent, get them to feel more, access more empathy, and be more emotion-focused in their parenting. How to help them slow down from problem-solving. And then we thought about how we bring them back together, what do we wanna accomplish? And from an attachment point of view, we are trying to create a corrective attachment experience where kids feel like; you weren't there for me, you don't love me, you love my brother more, or you were an alcoholic, or mom and dad fought. Whatever variety of reasons got in the way of parental attention.
Dr. Sutton: (10:29)
Or you were too involved and too intrusive and too controlling. We know, simplistically, those two patterns exist in all our cases, some variation of it. And we wanted to see if kids could negotiate their way into a better relationship, which from an attachment point of view is exactly that. I'm tied up in my insecure attachment knot, I’m defensive. And we wanted to try to untie the knot and say, “Hey, I'm hurting. I feel bad. This is why.” And we wanted our parents to say, “oh my God, I'm so sorry. Things were tough. I shouldn't have been that way.”
Dr. Sutton: (11:17)
Engage that attachment part of them to suit their child.
Dr. Diamond: (11:21)
Right, and be able to. Not that it's the whole story. It's just for an adolescent they're so burning to be heard and understood. And until you validate some of their resentment and animosity perspectives, it's for them to wanna cooperate. In that case, we often talk about that. It just exemplifies this as the alcoholic parent who goes away to drug treatment. Come home two years later, 18 months later, all cleaned up and like, “I'm ready to be your parent again.” You know, the kids like, “who are you kidding? Why did you ruin my life? You've been gone. Why would I let you walk in and tell me to go to bed at eight o'clock?”
Dr. Diamond: (12:15)
So, it's very clear in that case that until the kid can talk about his hurt and rejection, and anger, the parents are never gonna be able to resume the role of parental guidance authority. And so that's how we sell it to parents, let your kid get the stuff off his chest. And we think he'll be a little more cooperative
Dr. Diamond: (12:43)
And then we try to move into task five where it's, you know, it's kind of back to day-to-day behavioral things, but we're trying to help parents position themselves to support and challenge their kid without being overcontrolling or neglectful.
Dr. Diamond: (13:06)
Some classic family therapy things, but trying to think about it from an attachment point of view. How do I provide a secure base and autonomy, but don't abandon you or don't overcontrol you? And again, just kind of use an attachment frame to kind of guide what we do. So we dismantle family therapy into these kinds of core components and play to them and have tried to think about the different challenges in each of these stages and some structure and guidance. And I think young therapists find, “oh my God, this is a scaffold that allows me to do profound therapy long before I thought I could. I thought I had to be Keith to do work.”
Dr. Sutton: (13:56)
That kinda gives some of those steps or that kind of direction of what to do next. Kinda pieces that oftentimes begin with family therapists.
Dr. Diamond: (14:07)
Just don't, you know, don't have the confidence. And so it's actually a twofold thing. And the last thing I'll say, on the one hand, we've given enough structure on the other hand. It's kind of the way we think about it is more in the EFT emotion focus, process-oriented world
Dr. Diamond: (14:29)
And that requires a lot of just savvy and self of the therapist and the ability to track the deep process in the room. And we're trying to teach therapists that as well, I think, and the model has both structure and depth to it.
Dr. Sutton: (14:50)
I think that process orientation takes some time to help shift our thinking to where I was in my experience and I'm a certified focused therapy supervisor, but that process orientation and kind of not getting caught as much in the content I think is so important. So it sounds like you're influenced by the work you're doing with Ivan and particularly his trust piece that you were talking about seems to, you know, when I think of attachment, I often think of trust and safety. And so that makes sense. And you were kind of having those incredible sessions you were getting with ABFT. You kind of were trying to then figure out, like, “how do I help create the steps to have that happen more in an intentional way?” And that kind of helping the kids really talk about their pain and really helping the parents to hear it and take it in helped to reconnect them and then made a lot of the other stuff easier. Some of the, you know, the hard side of the hybrid kinda rules, consequences, you know?
Dr. Diamond: (15:59)
Yeah. It helps kids talk, and accept their attachment needs again.
Dr. Diamond: (16:06)
So I really do love my mom. I really do want her around. And if she's willing to be there for me more, or give me more space then I'd like to have her on my team.
Dr. Sutton: (16:18)
Yeah.
Dr. Diamond: (16:18)
So that's because adolescents do actually want to talk to their parents and have a connection. Their parents often think, “oh, they're teenagers and they don't.”
Dr. Sutton: (16:31)
So tell me a little bit about that too. I mean, you've done a bunch of research on this. I know that you've also applied this to different issues and you know, I think I forget exactly. Is it listed as evidence-based or what's the kinda listing for it?
Dr. Diamond: (16:45)
Yeah, when I was working I think one of my bigger commitments, professional commitments, has been to try to keep family therapy on the map of modern healthcare. And I think, although I love the therapy part and love the art artistry of it. I sort of got socialized by my two mentors, both Howard and Guillermo who were researchers to say, if we don't as a field, get some evidence going, you know, we're just gonna be left behind in the insurance panels and do we get taught in schools or not? And I mean, in Europe, this is deeply ingrained. If you're not on the panel in Sweden they don't pay for it.
Dr. Diamond: (17:47)
You know, so it's never quite come to that here, but I think family therapy struggles here. In a lot of places, I know they still struggle to get reimbursed for family therapy. They can't see parents alone for child therapy. They won't pay for a parent-alone session even though it's in the service of moving the kid forward. So, I think I've always had a value set of let's keep showing these works. Let's do research and it was a tall mountain to climb. Everyone thinks, “oh, let's do a little research.”
Dr. Sutton: (18:31)
Yeah.
Dr. Diamond: (18:32)
You know, it's a long, hard climb, and getting funding is a long, hard climb, and then publishing the data, doing a study. We just finished one study, took two years to get the grant funded, you know, you're right and it gets rejected. You write it again, you know, it took six years to collect the data.
Dr. Diamond: (18:56)
And then a year after that to write at least the main outcome paper, so seven years.
Dr. Sutton: (19:02)
Wow. It's a lot of work throughout.
Dr. Diamond: (19:05)
For one study and every day of that study, it's not like, “oh, okay, go ahead and go.” Every day of that study it was “Can we recruit, are these cases working? Are we getting it? Will they do it”
Dr. Diamond: (19:22)
It's a lot of work.
Dr. Sutton: (19:24)
And a lot of the funding has predominantly, I think, tell me if I'm right wrong here, go to like substance abuse treatment. I know there are a number of different evidence-based models for adolescents and substance abuse. But one of the things I like about your model too is it's one of the only models that focus on an internalizing disorder such as depression. And I think the first research you did was on kids that had made a suicide attempt, is that right?
Dr. Diamond: (19:51)
We actually started with depression. I was in an inpatient unit and it was all around, you know, every kid that got admitted. So we kind of got our first grant, our first NIMH grant around depression. But at the time this was the sort of mid-nineties, and the suicide field was still tremendously underdeveloped.
Dr. Diamond: (20:18)
Even in the funding in most studies, they would reject the kids that were suicidal. Like people would say, “oh, that's too difficult, high risk. Let's not put them in our studies.” So there was really a big push in the late nineties to start funding suicide research. So we, you know, started adapting some of the work to that. And it's really the center of my identity. Now I'm really both a prevention and treatment person. But the interesting thing about suicide is, you know, for us family therapists it's just a symptom. It's the warning flag that something's amiss. But you're working with kids with trauma. You're working with LGBTQ kids who are being bullied. You're working with kids with anxiety disorder. You're working with kids with, I mean, it's quite a comorbid population not isolated. So I think a lot of what we learned was how to work with a lot of, as you're saying a lot of internalizing kids. Now there are a lot of family interventions.
Dr. Diamond: (21:35)
Not many of them have done enough work to become classified as empirically supported. We are and we've done enough studies and we're on the SAMSA, what used to be the N-reps website. So we climbed the mountain and now we're considered. You know, what are the treatments for adolescent depression and suicide? Along with CBT and medication, and now DBT, a family therapy model is on the list. And with that, I feel some pride about that.
Dr. Sutton: (22:12)
It's good.
Dr. Diamond: (22:13)
Sustained a role in the field.
Dr. Sutton: (22:18)
And I think you've applied this also to some other issues too. I remember talking one time maybe to self-harming and maybe to gay, lesbian, or bisexual teens. Can you talk a little bit about that?
Dr. Diamond: (22:36)
Yeah, so probably our most systematic adaptation we'll call it, you know, kind of moving to another distinct enough population. That's different enough from our regular depressed kids who have really been in the LGBTQ arena.
Dr. Diamond: (23:01)
My colleagues, Gary Diamond now in Israel, and Jody Russon now at Virginia Tech have really kind of systematically moved the work forward. Gary particularly has done studies on the LGBTQ with the gay and lesbian adult population. And Jody's really picked up the trans kids, she's in more systematic work in that population. The exciting thing about Gary's work also has been that he has done more work with adults, young adults, and teenagers.
Dr. Diamond: (23:41)
So a lot of his patients are 27-29 all in Israel. And so it's been some very exciting work about family therapy with older kids who are living on their own, maybe married.
Dr. Diamond: (23:56)
Bring in grandparents, parents, you know, into a therapy process for some short-term structured trauma work, if you will. I've really loved that adaptation so that's been our biggest dramatic adaptation and we have published the most in that area and adopted adaptations to that.
Dr. Sutton: (24:26)
Yeah. I think sometimes people forget that you can do family therapy with adult children if the parents are alive. I actually used principles of attachment-based family therapy with a mom in her late eighties and a son in his late sixties the mother had also immigrated from China
Dr. Diamond: (24:55)
Oh, wow.
Dr. Sutton: (24:56)
It's just, you know, the model was really helpful to them. It was just helpful in repairing, you know, some of the distance that they had and really kind of strengthening that connection even this far past.
Dr. Diamond: (25:16)
I mean, the way I often say it in my, when we do trainings is for those of you doing adult individual psychotherapy, probably 40% of the time, you're still talking about their parents. What did they do or didn't do? She loved me. She didn't love me. And I think you can use the ABFT technology, if you will, to invite that parent in and say, “look, let's try to address some of these old hurts and you know, why spend the last 20 years of mom's life resenting her and why not sit down, have it out and see if we can't make these last few years together beneficial and hopeful.
Dr. Diamond: (26:09)
And I think the ABFT model allows you to plan for that in a way that increases the likelihood of it working.
Dr. Sutton: (26:13)
Exactly, sometimes I talk to some clients when it seems like that would be very helpful or like, you know, let's at least give it a shot, maybe hopeless, and it's not gonna change. But you know what, at least you can feel like I tried and when the parent passes away you know that you did all that you could.
Dr. Diamond: (26:29)
Yeah, right.
Dr. Diamond: (26:33)
And, I think the way we've broken it up, you know, that if we would meet alone with the parents first we would get to know them and understand their needs. And, you know, there's a lot of preparation so that when we bring them together, nobody's feeling like they're getting thrown under the bus.
Dr. Sutton: (26:50)
Yeah, I mean, what you're speaking to is what I love about systems work, you know, because I on an individual level do CBT and EMDR. But then oftentimes, well then I bring in a partner, you know, kinda access some of those core beliefs. Then bringing the parent to actually work on some of those traumatic events where the core belief actually started.
Dr. Sutton: (27:16)
You know, even a client of mine who was in his early thirties, we did some good EMDR around trauma and you have these questions like, why have parents reacted this way during that time? So we got them on the laptop and, you know, had a talk with them. And the mother said, “oh my gosh. I feel so bad. You've been thinking, I thought it was your fault, you know when you were seven.” So yeah, such a nice shift that, you know, we can do with the parents rather than necessarily spending years kind of doing it through our relationship.
Dr. Diamond: (27:48)
Yeah, kind of accelerates that work. How did that impact the EMDR work afterward?
Dr. Sutton: (27:57)
It was very helpful. I mean, he had an experience of molestation by a babysitter when he was young. The parents, you know, intervened and he got the impression that he was in trouble and that stuck. And so when he actually got that from his mother saying, “my gosh, it was not, that was not you at all. That was not your fault. I kind of separated you and so on to kind of find out what was going on and such yeah.” And further, in the EMDR, he was able to shift some of that toxic chain and I've really gotten into more of the complex trauma lately.
Dr. Diamond: (28:34)
That's just great. You know, we're working with Newport Residential Facility.
Dr. Sutton: (28:43)
Yeah, Newport Academy.
Dr. Diamond: (28:44)
Their staff is cross-trained, they're doing ABFT, and a lot of them now have learned EMDR. And I'm really kind of excited about the interface of those two modalities and how because so many of our kids and so many of our parents are stuck in trauma and we can't get them to move because of it.
Dr. Sutton: (29:03)
Yeah.
Dr. Diamond: (29:03)
We're trying to figure out from the other side how to integrate it into the family therapy work so that it could facilitate that. So that's a really exciting area to be in.
Dr. Sutton: (29:19)
And I've used it with even a teenager and the family. The attachment sessions are going really well, you know, actually helping make a significant shift as a teenager whose father reacted and pulled out the belt years earlier. It didn't actually hurt, but that changed their relationship and the dad was kind of more of a shut-down guy. He had immigrated from Chili and he was kinda emotionless then broke into tears and said, you know, “I never wanted you to have that experience” that he had as a child. But the child still had some of that emotional reactivity so we did some EMDR around that and then another ABFT session.
Dr. Diamond: (30:03)
Interesting.
Dr. Diamond: (30:06)
We often find exactly that but let's be humble. Sometimes family therapy is just not enough. It's good stuff. And the sessions you're talking about, who wouldn't wanna be doing those? But we're always referring to the kid afterward to fix the residues of these traumas and the emotional reactivity. And so trying to think multimodal, I think it is really a direction family therapy should be thinking. I think that CBT work, they've taken off, you know, and in the CBT and DBT studies around suicide and depression. it's all multimodal, they're not, you know, they call it DBT, but it's family group, support group, family therapy, and Group therapy,
Dr. Sutton: (31:04)
And actually, you know, speaking of DBT and actually self-harm. Had you done a research study on self-harm non-suicidal self-injury with adolescents on campus?
Dr. Diamond: (31:15)
You know, we've never done that as the primary problem, 30-40% of the kids in our last study reported self-harm. So we know as their depression goes down and there, you know, self-harm goes down as well. So it's definitely a sort of byproduct. I think you're right though, maybe it is what you're thinking. The cutting it's such self-regulating energy for their emotional intensity.
Dr. Diamond: (31:51)
And the question becomes is the emotion regulation experience in family therapy enough to internalize some new skills or do you also need to be doing some DBT and meditation work around that or also doing some EMDR?
Dr. Sutton: (32:13)
I was gonna say, you know, the way I think about it too is that I ask the kids, “when you feel like hurting yourself, whether that be suicidal or self-harm, can you turn to your parent, and if not, why not.” Because you think, oftentimes when you can reconnect that attachment, then they're able to turn with their pain and ultimately get what they hadn't been getting, which is that co-regulation which internalized. So definitely adding mindfulness and you know, the DBT I think are all really good to have those additional skills. But to actually have that, you know, ability to kinda connect attachment in for support, I think it helps with the regulation. Internalizing the ability to self-soothe. We were also working with parents and helping them learn how to stay regulated.
Dr. Diamond: (33:06)
That's what I was gonna say. I think our, you know, in our next study, what we'd like to do is intensify the parent part of the treatment.
Dr. Sutton: (33:16)
Yeah.
Dr. Diamond: (33:17)
Because for so many of our kids the parents just are as dysregulated as the kid.
Dr. Sutton: (33:23)
Yeah.
Dr. Diamond: (33:23)
And to try to teach them some self-management skills, some self-soothing skills we hope that improve their parenting. Giving them an experience of competent parenting helps them internalize a new sort of narrative or image of themselves. “Oh, I can be a good parent and this can work. I don't have to slam the hammer on them, I can just talk.” But not unlike the kid, it just sometimes isn't quite enough, you know?
Dr. Sutton: (33:56)
Yeah, definitely.
Dr. Diamond: (33:58)
Let's do 12 weeks of EMDR with our parents as a prerequisite
Dr. Sutton: (34:03)
Disarming some of those triggers that are hard for them to stay present. But some of the parents I work with, that I talk about, it's like, “we wanna be that rock in the ocean that the waves are crashing up against, rather than that kinda rowboat just kind of getting tossed.”
Dr. Diamond: (34:18)
Right.
Dr. Sutton: (34:20)
And helping them to be able, kinda do that.
Dr. Diamond: (34:22)
Well, I would like to do more of that.
Dr. Sutton: (34:24)
Yeah.
Dr. Sutton: (34:26)
Tell me about the eating disorder work that you're doing research on.
Dr. Diamond: (34:31)
Yeah. So we've been really, you know, fortunate in the eating world, the FBT world, the Maudsley world.
Dr. Sutton: (34:41)
That family-based therapy for anorexia.
Dr. Diamond: (34:43)
Yeah. Which really comes out of the old Munchkin strategic tradition and, you know, they themselves have gone through a little bit of self-examination, whether we are too behavioral.
Dr. Diamond: (35:02)
Really the essence of that model is parental control and we're gonna make our kid eat. And they sometimes feel like, “whoa, we're up against such resentment here that we just, you know, we need to do something a little different for a while.” And so a lot of FBT people have turned to us as a model for a kind of a pathway of, “oh, when I need to do more interpersonal work FBT can guide me in it.”
Dr. Diamond: (35:36)
We've actually done a lot of work with the Maudsley team in England and Ivan. And, you know, he was a giant when I was growing up and now he's calling me over Guy and come teach my staff, do this work. And, you know, he has just been a great collaboration, but there are two ways they're using us. One when the anorexia cases are just up against so much resistance, it's sort of like, well, let's change gears here. Let's figure out why you're so resistant to your mom taking care of you. Let's get why you don't go to your mom for help. And the other big area they are using is bulimia cases, they tend to look a little bit more like depression cases, with more chaos, more family conflict, and more emotional disruption.
Dr. Sutton: (36:36)
Just regulation.
Dr. Diamond: (36:37)
So there's a lot of interest and there's been remarkably little research in the area of family therapy and the FBT study.
Dr. Sutton: (36:44)
Yeah.
Dr. Diamond: (36:45)
So we've been supporting Maudsley and doing it. They have a pilot project going on and we've started our own pilot study. We're about to finish our first 10 cases too, you know, work with bulimic cases. And for the most, you know, the model fits pretty well. We're doing this in a collaboration with CBT.
Dr. Diamond: (37:17)
You know, it's really a lot more about how do we integrate these when kids are purging five times a week, you can't just sit around talking about your feelings. You got to do something concrete to manage that, but they're missing something and we have felt we need something. So we're partnering up and that's nice to learn how to pace those two sequences and how to do more behavioral management, but also do it from a more attachment kind of frame.
Dr. Sutton: (37:51)
Yeah.
Dr. Diamond: (37:52)
So far it's gone pretty well. There are a couple of cases that are hard, but yeah. Always get those.
Dr. Sutton: (37:59)
Yeah. I actually get some training with care. Down at Stanford, we had, I always forget. And she did actually a training for us and then a 10-week, one-way mirror series, which was really great. And I really like the model in that it really focuses on a structural model essentially of helping kind of parents to access their kind of instincts to take care of the children. And I think anorexia particularly because, you know, the kids almost become phobic of eating, you know, and get so reactive that sometimes it's so overwhelming for the parents. And again, they end up seeing it as an attack sometimes rather than care. So definitely makes it understandable how the based work would be helpful in potential against anorexia.
Dr. Diamond: (38:55)
And it's actually interesting that this group is the first one I saw. They did a comparison between the FBT and a General Family Therapy Model, just kind of general and both models worked well in the outcome research.
Dr. Diamond: (39:13)
So, I think it was a little crack in like maybe this kind of behavioral control isn't the only mechanism that these families need. And maybe there is some sort of just relational connection. Better communication and more emotional containment help the FBT world try to think a little more broadly.
Dr. Sutton: (39:34)
Yeah.
Dr. Sutton: (39:39)
Yeah, I think that's a tough place. And especially, I know in their first stage of their work of the kind of the repeat that it's like, you know, this kid is gonna die and yeah. But it ends up yet hitting up against that so hard. And is there any way to kind of help that go sooner or so on? You know, there was one part you were mentioning earlier about, you know, part of the attachment session is kind of helping create that corrective experience. And I think that you know, that piece, I think is so important. Because I think oftentimes in individual therapy, that's really a big piece of goal or at least, you know, particularly from a dynamic perspective of having that different relationship and the transference countertransference and control mastery. Not fulfilling those roles, the person is able to have a different experience. And yeah, I just wanna get, I guess your thoughts on that piece and so on. I mean the way again, I conceptualize it, I think that's always great. And the measure of the relationship with the therapist is essential, I want them to actually have the corrective experience with their attacking figure the whole rest of the week and, and so on.
Dr. Diamond: (41:08)
I mean, I think there's a number just to frame that answer like this there's a number of individual therapies that have adopted a kind of an attachment framework schema. Therapy does, you know, there's a number of other people and in some ways, I always say we're all doing the same work.
Dr. Diamond: (41:40)
You know, we're trying to be a secure enough base so these kids can develop a more coherent view of themselves and their history, And by coherent, I mean, not only be able to articulate it more honestly but feel the feelings that come with it.
Dr. Sutton: (42:03)
Yeah.
Dr. Diamond: (42:03)
Between the hurt, and the disappointment and not feeling like I gotta push that side away and just come up with some story that helps me explain. But it's like, I can be honest about how bad it was, feel legitimate to talk about it. And I can rather repress or contain these feelings, which leads to emotional dysregulation because I'm spending energy hiding from vulnerable emotions. I mean, this is an EFT kind of principle. I'm gonna be able to integrate those feelings more. And I think individual work can do a lot of that.
Dr. Diamond: (42:45)
And all of us are good parents to our patients and try to recreate an experience of trust and safety for them. So they can do some internal reflecting work.
Dr. Diamond: (43:04)
You know, whether there's something accelerated, if the actual parent comes in the room and says, you know, “I'm sorry, or shouldn't have been that way or tell me more.” We think there's existentially something that gets accelerated, more profound.
Dr. Sutton: (43:23)
Yeah.
Dr. Diamond: (43:24)
In Gary Diamond’s study, he compared enactment, that's task four of ABFT, bringing the parent in, getting everybody ready, and then getting off your chest and parents listening. And, oh my God, I didn't believe it. And he randomized some patients and other patients got the two-chair technique.
Dr. Diamond: (43:53)
And the question was if you do this imaginary, is it relatively better to do it in reality, the real relationship versus just thinking through and what would I say to my mom?
Dr. Sutton: (44:10)
Yeah.
Dr. Diamond: (44:11)
And the study basically found both treatments worked well in reducing anxiety and depression. We know EFTs are powerful and the ABFT works, but the patients reported improved perceived attachment with their parents as a result of the real. So it had a more sustained relationship impact. Whereas the imaginable work helped me change my internal view of myself, it didn't change my real relationship,
Dr. Sutton: (44:44)
Relationship and reality.
Dr. Diamond: (44:46)
So it's, you know, an interesting way, different.
Dr. Sutton: (44:51)
You know, one of the cores of systemic thinking is that you create more lasting change from that shift in the system to help support the individual change.
Dr. Diamond: (45:02)
Yeah.
Dr. Sutton: (45:03)
I mean the relational part of the connection with the adolescents, particularly in your model. Because I think that, you know, I know that a lot when I'm teaching family therapy or so on with individual clients that maybe are, or therapists that are worried about that. The teenager might not want to talk to the parent or it's gonna ruin the relationship between them if they're bringing the parent into the therapy or working with them together. And some of those concerns around the holding space for the adolescent. Just wondering if you can maybe speak to that because I think that, you know, ultimately you're trying to get them to access their vulnerability.
Dr. Diamond: (45:45)
I mean, I think we think about it in two ways and this is all task two.
Dr. Diamond: (45:53)
You know, when we talk about a task, it's not something that you do. Okay, I'm now doing, you know, it's a set of principles, a set of mechanisms that I'm gonna play out because I'm trying to accomplish something. Because I might be way down the line six months later and say, “oh, I gotta go back to task two and I gotta get a little bit more of this” and you're sort of moving back and forth between. So in that task, we do think about them creating us as a transitional object as the old Winnekot would say “That we create.”
Dr. Diamond: (46:35)
I got a kid right now, actually, my bulimic patient, who's been in a bunch of eating disorder programs that have all been sort of, you gotta change and I've been totally on his side.
Dr. Diamond: (46:57)
Of course, you're angry and of course, you're mad. You should be mad. And he says to me, “I've never felt like a therapist has been on my side before.”
Dr. Diamond: (47:09)
I have always felt they're on my mom's side.
Dr. Diamond: (47:12)
You are the first person that I feel represents me but he didn’t say it like that.
Dr. Sutton: (47:16)
Yeah.
Dr. Diamond: (47:17)
But I think that was a powerful joining. So I think that's one of our mechanisms. We just really side with and empathize with their story. But I think the other mechanism is that we do explicitly ask about their attachment narrative and say, you know, “tell me how bad it was. Tell me how mad you are. Tell me the things your parents do that you felt were so unjust.” And I think in doing that, it primes them to, you know, it helps them articulate that story of injustice that they experience. And it primes them so that when we go, ready to do the family work, that story's been told and they're more comfortable with it. They're willing to acknowledge the hurt that they feel. And, I think those two things together allow us to transition back into family peace,
Dr. Sutton: (48:25)
Like even a mini exposure to kinda get ready.
Dr. Diamond: (48:29)
Exactly, yeah. And it's poignant, you know.
Dr. Sutton: (48:39)
Isn't there a key question in that session with the adolescent, I forget what it was. Something to the effect of like, when did you give up on your parents?
Dr. Diamond: (48:51)
When did you fire them? We sometimes, yeah. Like what's happened to make you so angry at them? You deserve to be angry. You should be angry. It's legitimate, but let's see if we can't describe it a little bit better. So it's not because most of the kids when they start to think about these things, it comes out totally dysregulated. I don't know what it is. I just hate them so much. Do you know? And we want them to say no, no, no. Let me tell you what it is. And let me tell you how I feel and let me cry about it. Let me really know the landscape of that disappointment as a way for them to capture their own sense of self.
Dr. Sutton: (49:43)
One client I was working, he was hospitalized, and I set up those sessions. I told him that next session I'm going to ask you when was the moment you kind of gave up on your parents. And he said, “oh, I don't have to wait. I can tell you right now. It's when I realized I was gay, but I didn't wanna be. And I started smoking pot and they busted me because of pot smoking and they just came down hard on me and they didn't even ask me what was wrong with me. And that's when I realized that I can't go to them.”
Dr. Diamond: (50:16)
Yeah.
Dr. Sutton: (50:17)
His being able to talk to his parents about that really was a key piece because it was kinda the moment that changed their relationship.
Dr. Diamond: (50:26)
Yeah. That's great, and I think a lot of kids have that kind of story.
Dr. Diamond: (50:35)
I mean, some kids it's just so chronic chaos, you know, I'd say 70% of our kids have a story. They don't know how to put it into words. They don't feel like they deserve to put it into words. With our depressed kids, you know, a lot of our depressed kids are actually pretty protective of their parents. You know, they got enough on their plate. Mom already has her own health problems.
Dr. Diamond: (51:07)
So they keep a lot of pain to themselves. I mean it's all kinds of variations.
Dr. Sutton: (51:13)
Yeah.
Dr. Diamond: (51:15)
But I think what you said is exactly right. And I think it's what the model does. It allows you to pinpoint those kinds of questions rather than just, “oh, let's talk about therapy and how you are. what do you mean?” It's like, no, tell me about the betrayal.
Dr. Sutton: (51:32)
Yeah, it's like the surgical kinda going right to that.
Dr. Diamond: (51:35)
Yeah, surgical.
Dr. Sutton: (51:36)
Yeah, actually what you're just saying, reminds me of the story. In one of the trainings, I was in one of the therapists who mostly did individual talk about, you know, thinking of a client of hers where, you know, the individual therapy would be the best. And then the trainer asked, “And why do you think that what's the client therefor or not?” The individual therapist was talking about, you know, having a place for the girl to talk and the therapist asked, “oh, and does she talk to her mom?” She said, “no, she doesn't wanna burden her because her mom has cancer.”
Dr. Diamond: (52:08)
Yeah.
Dr. Sutton: (52:09)
And so right there was the answer that this kid was holding everything inside because she didn't want to burden the parent. And actually, the parent wanted to be a parent. And even though the parents had cancer, they still wanted to be able to take care of their dog.
Dr. Diamond: (52:26)
You know, in these less insidious cases, I remember a case where a mom was dying of cancer and everyone knew, but the mom didn't wanna upset anybody. So she didn't ever want to talk about it.
Dr. Diamond: (52:45)
And we just really helped her see that you know, not talking about it is just eating them up. And you know, so our task four was mom coming and saying, “look, you know, how are you handling this? What's this like for you?”
Dr. Sutton: (53:04)
Yeah.
Dr. Diamond: (53:05)
Girl, you know, just falling apart, holding back all this pain. But it was about, and I think a lot of the ABFT is that it's not always these hostile chronic things. Can we talk about the things that are difficult? Divorce is a classic one. How many cases have you had where the parents got divorced? It's messy as hell, but we never talk to the kids about it. Oh, he's eight. He doesn't know. And the kids are totally torn up and confused and like, you know, maybe we should contain them and hold them.
Dr. Sutton: (53:43)
Yeah, with the Jim Kinds model, the one that I work with in the Jim clinic. Particularly he, you know, often talks about that, to have that parental hierarchy that parents need to be able to handle the hottest topics. That means talking about the trauma, talking about, you know questioning sexual orientation, talking about the divorce. And until those conversations can really be had, the kids can't necessarily feel that sense of trust in putting them into the parents' hands and trusting that the parents can handle things.
Dr. Diamond: (54:17)
That's great. That's exactly why I love that we use hot topics.
Dr. Diamond: (54:25)
One to engage the kid, because this is what's important to them. And two to have a sort of exposure experience of talking about a hot topic and not dying because of it.
Dr. Sutton: (54:38)
Yeah, exactly.
Dr. Diamond: (54:39)
We finally talked about it and my head didn't blow up, you know? I didn't have a heart attack.
Dr. Sutton: (54:45)
And the therapist can help it go well.
Dr. Diamond: (54:49)
Yeah, but I love that.
Dr. Sutton: (54:51)
So thank you so much for taking the time today. This is really great. And it's always good to talk with you about, you know, putting these ideas together and so on to get ABFT out there and more people learning about it.
Dr. Diamond: (55:06)
Yeah, I love it. I always love talking to you about therapy. You have a great mind for kindred souls.
Dr. Sutton: (55:14)
I know, right?
Dr. Sutton: (55:26)
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