Therapist Interventions Associated with Productive

Emotional Processing in the Context of

Attachment-Based Family Therapy for Depressed
and Suicidal Adolescents
NOA TSVIELI*
OFIR NIR-GOTTLIEB*
CHEN LIFSHITZ*
GUY S. DIAMOND†
ROGER KOBAK‡
GARY M. DIAMOND*

Productive emotional processing is considered a key change mechanism in attachment-

based family therapy (ABFT). This study examined the impact of attachment-based family
therapy therapist interventions aimed to promote productive emotional processing of pri-
mary adaptive emotions in a sample of 30 depressed and suicidal adolescents who had par-
ticipated in a larger randomized clinical trial. Results of sequential analyses revealed that
relational reframes and therapists’ focus on primary adaptive emotions were associated
with the subsequent initiation of adolescents’ productive emotional processing of primary
adaptive emotions. In contrast, interpretations, reassurances, and therapists’ focus on ado-
lescents’ rejecting anger toward their parents were all followed by the discontinuation of
adolescents’ emotional processing that had already begun. Finally, therapists’ general
encouragement of affect and focus on adolescents’ unmet attachment/identity needs were
associated with both the initiation of adolescents’ productive emotional processing, and
with the discontinuation of such processing once it had already begun. Theoretical and
clinical implications are discussed.

Keywords: Therapist Interventions; Emotional Processing; Attachment-Based Family

Therapy

Fam Proc x:1–17, 2019

D epression and suicidality are common among adolescents, with the estimated lifetime
prevalence for major depressive disorder being 11.0% (Avenevoli, Swendsen, He, Bur-
stein, & Merikangas, 2015), for suicidal ideation being 12.1%, and for suicide attempts
being 4.1% (Nock et al., 2013). Indeed, suicide is the second leading cause of death among
U.S. adolescents (Stone et al., 2018). Needless to say, developing, testing, and refining
effective treatments to combat adolescent depression and suicide is crucial. One

*Ben-Gurion University of the Negev, Beer-Sheva, Israel.

†
Drexel University, Philadelphia, PA.
‡
University of Deleware, Newark, DE.
Correspondence concerning this article should be addressed to Gary M. Diamond, Department of
Psychology, Ben-Gurion University of the Negev, P.O.B. 653, Beer-Sheva 8410501, Israel. E-mail:
gdiamond@bgu.ac.il.
This study was supported by grant number 2011279 from the United States-Israel Binational Science
Foundation.

1
Family Process, Vol. x, No. x, 2019 © 2019 Family Process Institute
doi: 10.1111/famp.12445
2 / FAMILY PROCESS

psychosocial treatment that has been shown to be efficacious with depressed and suicidal
adolescents is attachment-based family therapy (ABFT; Diamond et al., 2014). ABFT is a
family based, experiential, emotion-focused treatment that has demonstrated efficacy in
three separate randomized clinical trials (Diamond, Reis, Diamond, Siqueland, & Isaacs,
2002; Diamond et al., in press; Diamond, Wintersteen et al., 2010). ABFT is listed as a
“proven treatment” on the Promising Practices Network (http://www.promisingpractices.
net) and received high scores by the Substance Abuse and Mental Health Services Admin-
istration’s National Registry of Evidence-based Programs and Practices (NREPP).
The model is rooted in structural family therapy (Minuchin, 1974), and informed by
multidimensional family therapy (MDFT; Liddle et al., 2001) and emotion theory (Green-
berg, 2012; Safran & Greenberg, 1991). The overarching framework, however, is attach-
ment theory (Bowlby, 1969). Without ignoring biological factors, ABFT therapists focus on
interpersonal family processes, such as adolescent–parent conflict, detachment, harsh
parental criticism, and/or family traumas (e.g., abandonment, neglect, abuse), that can
cause, maintain, or exacerbate depression in adolescence (Chiu, Tseng, & Lin, 2017;
Goschin, Briggs, Blanco-Lutzen, Cohen, & Galynker, 2013; Nelemans, Hale, Branje,
Hawk, & Meeus, 2014; Sentse, Lindenberg, Omvlee, Ormel, & Veenstra, 2010; Sheeber,
Hops, & Davis, 2001). Not only do such negative processes have a detrimental effect on
the adolescent’s view of self (e.g., lower self-esteem), but they can undermine adolescents’
trust, confidence in parents’ availability, and sense of safety in the attachment relation-
ship (Kobak & Bosmans, 2018). This decreases the likelihood that adolescents will turn to
their parents for understanding, support, and guidance when experiencing distress,
regardless of whether the distress is biologically based, the result of negative family pro-
cesses (e.g., parental criticism) or extrafamilial in nature (e.g., peer victimization). Lack of
trust and confidence in parents’ availability leaves adolescents feeling less connected,
more alone, helpless, and more vulnerable to depression and suicidal ideation (Adam,
Sheldon-Keller, & West, 1996; Allen, Porter, McFarland, McElhaney, & Marsh, 2007).
Thus, the primary goal of ABFT is to decrease parental criticism, increase parental empa-
thy and warmth, and restore trust, a sense of safety, and confidence in the adolescent–
parent relationship.
To accomplish these goals, there are four essential ABFT treatment tasks which are
introduced in sequence. Each task may take one or several sessions to complete. The first
task, the relational reframe (Diamond & Siqueland, 1998), is conducted in the context of
the initial conjoint session and is aimed at shifting the focus of therapy from the adoles-
cent’s depression/suicidality per se to the quality of the adolescent–parent attachment
relationship. Specifically, the therapist explores the degree to which adolescents can turn
to, and obtain support, validation, and protection from their parents during times of dis-
tress. The second task, alliance-building with the adolescent, takes place in the context of
individual sessions with the adolescent. During these sessions, the therapist works to
forge a trusting relationship with the adolescent, identify core family dynamics that fuel
conflict or disengagement, help the adolescent explore and process emotions and needs
related to the relational rupture, and prepare the adolescent to discuss these issues with
their parents in future in-session enactments (i.e., corrective attachment/identity epi-
sodes). The third task, alliance-building with parents, is conducted in the context of ses-
sions alone with parents. During these sessions, the therapist focuses on reducing
parental distress and improving parenting practices. The task begins with a supportive
exploration of parents’ strengths and competencies, and then parlays into an exploration
of parents’ own childhood history and current stressors (e.g., psychiatric distress, marital
problems) which may be affecting their ability and availability to parent. When parents
experience validation and empathy regarding their own vulnerabilities and challenges,
they become more empathic toward their adolescent’s struggles. In this softened state,

www.FamilyProcess.org
TSVIELI ET AL. / 3
parents become more receptive to hearing and taking responsibility for their adolescent’s
unmet attachment/identity needs, and learning parenting skills, including affective
attunement and emotional facilitation (Gottman, Katz, & Hooven, 2013). Parents are then
prepared to use these skills in subsequent corrective attachment/identity episodes.
The fourth task, corrective attachment/identity episodes, is the culmination of the work
completed in the first three tasks. Such episodes, conducted in the context of conjoint ses-
sions, are designed to provide the adolescent with a new, in vivo corrective experience of
their relationship with their parents—an experience in which they are able to express
adaptive emotions in a clear, regulated manner and feel like parents are responsive,
empathic, and available. These episodes typically begin with the adolescent identifying
past and present negative family processes (e.g., criticism, neglect) that have violated the
attachment bond and damaged trust (i.e., relational ruptures). As parents respond to their
adolescent’s complaint in a non-defensive, validating, and empathic manner, adolescents
gradually become more forthcoming (Diamond & Liddle, 1999). They further disclose pri-
mary adaptive vulnerable emotions associated with the relational rupture (e.g., hurt, lone-
liness, and fear), and assert their unmet attachment/identity needs (e.g., “I need you to
show me that you care about how I am feeling”). This iterative process of disclosure on the
part of the adolescent, and empathic validating responses on the part of the parent, serves
to restore trust and security in the relationship (Kobak & Bosmans, 2018). As trust
improves, the adolescent becomes more willing to share previously unspoken thoughts,
feelings, and events related to their depression or suicidal ideation (e.g., feeling like a bur-
den to parents, hurt associated with being shunned at school, etc.). As parents respond in
an attuned, empathic, curious, supportive, and deeply caring manner, adolescents feel
comforted, validated, and less alone. Consequently, they are more likely to go to their par-
ents to seek comfort, protection, and guidance the next time they feel suicidal. Moreover,
such conversations between adolescents and their parents promote adolescents’ perspec-
tive taking, emotion regulation capacity, and problem-solving skills (Hershenberg et al.,
2011; Kobak & Duemmler, 1994)—all protective factors against depression and suicidal
ideation (Becker-Weidman, Jacobs, Reinecke, Silva, & March, 2010; Hasking et al., 2010;
Sheeber et al., 2001; Tamas et al., 2007).
As previously mentioned, in order to prepare adolescents for such conjoint corrective
attachment/identity episodes, therapists meet alone with the adolescent beforehand for a
number of individual alliance-building sessions. During these individual sessions, the
therapist works to help the adolescent access, fully connect to, and articulate their pri-
mary adaptive emotions in a clear, regulated manner. This process is called productive
emotional processing (Greenberg et al., 2007). Such processing is important because
depressed and suicidal adolescents often present for therapy either in a state of global dis-
tress (e.g., “Life just sucks”) or with high levels of rejecting anger (e.g., “I hate my school,”
“I hate my stepmother”). According to emotion theory (Greenberg, 2002, 2004, 2012; Pas-
cual-Leone & Greenberg, 2007), global distress and rejecting anger are secondary emo-
tions because they are poorly differentiated (e.g., vague, general, void of autobiographic
information, and therefor low in meaning), do not reflect the adolescent’s core experience,
and are not helpful in terms of instructing the adolescent regarding what they need in
order to feel better. Because secondary emotions like global distress and rejecting anger
are poorly differentiated and expressed in a dysregulated, blaming manner, adolescents’
expressions of such emotions often lead parents to feel frustrated, incompetent, blamed, or
attacked. Consequently, parents are likely to withdraw, become defensive, or blame the
adolescent in return—responses that exacerbate the relational rupture and leave the ado-
lescent feeling even more alone. In contrast, primary adaptive emotions reflect the adoles-
cent’s initial and natural response to a given situation (e.g., hurt associated with feeling
unloved, fear of being verbally abused, grief associated with loss, assertive anger in

Fam. Proc., Vol. x, xxxx, 2019

4 / FAMILY PROCESS

response to boundary violations) and activate his or her adaptive action tendencies (e.g.,
reaching out for support when feeling hurt, asserting boundaries when feeling threat-
ened). When adolescents exhibit their primary adaptive vulnerability and longing in rela-
tion to attachment injuries and other negative life events, parents are more likely to be
empathic. Such vulnerability activates parents’ natural caregiving instincts and increases
the likelihood that they will respond with care, validation, comfort, and protection. Like-
wise, the adolescent’s ability to assert their unmet needs in a non-blaming, regulated man-
ner increases the likelihood that parents will respond by trying to meet their child’s needs.
In order to facilitate the productive emotional processing of primary adaptive emotions
with depressed and suicidal adolescents, ABFT therapists primarily use three emotion-
focused and attachment-focused interventions (Diamond, 2014). These interventions
include: focusing on primary adaptive emotions; focusing on unmet attachment/identity
needs; and relational reframes. In order to focus on primary adaptive vulnerable emotions
(e.g., hurt, grief, sadness) and assertive anger, the therapist first listens to, tracks, and
validates the dominant yet maladaptive or secondary emotions being expressed. For exam-
ple, the therapist might listen empathically to the adolescent as she describes how
annoyed she is that her mother teases her about being overweight: “She is such a hyp-
ocrite! She herself is overweight. . ..” After a short while, however, the therapist looks for
cues of underlying, less dominant but core primary adaptive vulnerable emotions, and
attempts to gently shift the adolescent’s attention to them. In this example, for instance,
the therapist might say: “I hear how mad you are. I can understand how your mom’s com-
ments would make you angry. I wonder, though, if in addition to your anger, it also hurts
when she says those things?” In this particular example, the adolescent responded by
beginning to cry and saying: “It hurts. It makes me feel like she wishes she had a different
daughter.” Alternatively, the therapist might explore the adolescent’s primary adaptive
assertive anger in response to her feeling disrespected. Such an intervention shifts the
focus away from the adolescent’s defensive, blaming, and belittling rejecting anger (e.g.,
“my mother is a hypocrite”) and, instead, onto her more productive, adaptive assertive
anger. The therapist might say: “Can you say something about the anger you are feeling?
What is it about?” In this case, the adolescent responded in a stronger, more regulated and
assertive angry voice: “That is not the way you treat your daughter. Parents are supposed
to make their children feel good, not bring them down.”
Focusing on unmet attachment/identity needs involves asking the adolescent what they
needed from their parent during a specific moment of distress. They may have needed
reassurance, comfort, to feel loved and valuable, or to feel protected. In one example, an
adolescent girl described how she had approached her mother in tears after breakingup
with her girlfriend. She described how her mother had responded with a combination of
relief and criticism of her ex-partner, and how frustrated and alone her mother’s response
had made her feel. In this example, the therapist responded by asking: “What did you need
from your mother in that moment?” As is often the case, the adolescent was clear about
what she had needed: “I needed her to just hold me and tell me that everything was going
to be O.K. [beginning to cry]”. Such interventions facilitate productive processing because
they tap into deep, fundamental attachment/identity needs that are an integral part of,
and lead to the activation of, powerful self-organizing and relational emotional schemes
(Safran & Greenberg, 1991). For instance, coming into contact with one’s unmet need for
comfort may elicit hurt and sadness, whereas coming into contact with one’s unmet need
for closeness may elicit loneliness, and coming into contact with one’s unmet need to be
protected and respected may elicit assertive anger (Auszra, Greenberg, & Herrmann,
2010).
The third intervention that ABFT therapists use to facilitate productive emotional pro-
cessing is the relational reframe. Reframes have long been considered a core family

www.FamilyProcess.org
TSVIELI ET AL. / 5
therapy intervention (Minuchin & Fishman, 1981). In ABFT, therapists use relational
reframes to shift family members’ focus away from the presenting problem (e.g., adoles-
cent’s depression or suicidal ideation), and the perceived causes of the adolescent’s depres-
sion or suicidal ideation (e.g., peer victimization, parents’ divorce) and, instead, onto the
ability of the adolescent to use their parents as a secure base during times of distress. A
paradigmatic relational reframe is when the therapist asks the adolescent: “When you
come home from school feeling miserable and alone, do you go to your parents to let them
know how bad you are feeling?” or “When you are feeling so bad that you want to die, why
don’t you go to your mom or dad for support?” Relational reframe interventions highlight
the fact that not only is the adolescent in distress, they are also alone with their feelings.
Such interventions usually elicit and amplify the adolescent’s primary adaptive hurt, sad-
ness, sense of loneliness, fear, and pain. For example, after one adolescent described how
he had suffered from bullying at school throughout his childhood, the therapist asked
whether his parents had been aware of what he was going through and how terrible it felt.
He responded by becoming visibly sad and crying: “No. Nobody knew. I felt like I was alone
in the world.” Such expressions of pain serve to motivate both the adolescent and their
parents to adopt relationship building as the primary goal for treatment (Diamond et al.,
2014).
The purpose of this study was to empirically examine whether therapists’ focus on pri-
mary adaptive emotions, focus on unmet attachment/identity needs, and relational
reframe interventions were indeed associated with adolescents’ productive emotional pro-
cessing of adaptive vulnerable emotions and assertive anger in the context of individual
alliance-building sessions with depressed and suicidal adolescents receiving ABFT. A
small number of previous studies have explored the impact of these interventions on cli-
ents’ emotional states in samples of young adults reporting unresolved anger toward a
parent. In one analogue study, in which young adults participated in a single emotion-
focused therapy session, relational reframe interventions led to increased arousal of sad-
ness, as evidenced by clients’ voice quality, voice signal, and speech fluency (Diamond,
Rochman & Amir, 2010). In a second analogue study, young adults’ retrospective reports
revealed that the sequence of relational reframe interventions followed by empty-chair
interventions was associated with decreases in rejecting anger and increases in primary
adaptive grief/hurt (Narkiss-Guez, Enav Zichor, Guez, & Diamond, 2015). Finally, in a
recent clinical trial comparing ABFT to individual emotion-focused therapy for young
adults reporting unresolved anger toward a parent (Diamond, Shahar, Sabo, & Tsvieli,
2016), ABFT therapists’ focus on primary adaptive emotions and unmet attachment/iden-
tity needs, but not relational reframes, was followed by young adults’ productive emotional
processing at a rate greater than chance (Tsvieli & Diamond, 2018). This study was the
first to examine the efficacy of these interventions among a sample of depressed and suici-
dal adolescents participating in family therapy. Such research is crucial in light of the fact
that depressed and suicidal adolescents often present for therapy either emotionally disen-
gaged or in a state of global distress, and helping them to access and process more mean-
ingful, differentiated, adaptive emotion states is both challenging and critical for the
therapy process. Such productive processing not only allows the adolescent to form a more
coherent narrative of their own experience and self, but also provides them with the
means to directly communicate their pain and unmet attachment and identity needs to
parents in the context of conjoint sessions.
Based on the treatment model, clinical experience, and prior research, we hypothe-
sized that therapists’ focus on primary adaptive vulnerable emotions and assertive
anger, therapists’ focus on unmet attachment/identity needs, and relational reframe
interventions would be followed by adolescents’ productive emotional processing of pri-
mary adaptive emotions at a rate greater than expected by chance. At the same time,

Fam. Proc., Vol. x, xxxx, 2019

6 / FAMILY PROCESS

based on both clinical experience and prior research, we hypothesized that a group of
control interventions (e.g., focus on rejecting anger, psychoeducation, interpretations,
reassurance, focus on core relational themes) that were more cognitive in nature, didac-
tic, abstract, focused on secondary emotions, or otherwise focused on non-emotional con-
tent would not be associated with immediately subsequent productive emotional
processing of primary adaptive emotions (Anderson, Bein, Pinnell, & Strupp, 1999;
Tsvieli & Diamond, 2018; Wiser & Goldfried, 1998). Moreover, based on the challenge of
sustaining productive emotional processing for an extended period of time (Diamond
et al., 2016; Kramer, Pascual-Leone, Despland, & de Roten, 2015), we hypothesized that
these control interventions would likely lead to the discontinuation of such emotional
processing once it had begun.

METHODS
Participants
Data were drawn from video recordings of 30 depressed and suicidal adolescents and
their families who completed 16 sessions of ABFT. Participants were randomly drawn
from a larger sample of 59 adolescents enrolled in a randomized clinical trial conducted in
a large city in the United States. In order to be included in the clinical trial, adolescents
needed to: (a) be between the ages of 12 and 18; and (b) report severe suicidal ideation
(SIQ-JR ≥ 31) and moderate depression (BDI II ≥ 20) at two time-points pre-treatment.
Participants were recruited from primary care centers, emergency departments, outpa-
tient facilities, inpatient hospitals, schools, churches, and the general community. Adoles-
cents evidencing imminent risk of harm to self or others, psychotic features, or severe
cognitive impairment were referred elsewhere. In the subsample included in this study,
participants’ age ranged between 12 and 17 (M = 14.86), and a large majority was female
(90%). Fourty-one percent of the participants in the subsample identified as White, 28%
African American, 17% Biracial, 7% Asian, and 7% Hispanic.
Therapists were nine M.A social workers and Ph.D. level psychologists, with clinical
experience ranging from three to 15 years. Therapists received training in ABFT and trea-
ted two pilot cases before treating actual study cases. During the course of the clinical
trial, they received weekly supervision from an expert ABFT supervisor.

Instruments
Productive emotional processing was measured using the Client Emotional Produc-
tivity Scale-Revised (CEPS-R; Auszra et al., 2010). This observational measure was
designed to assess the productivity of clients’ emotional expressions in therapy. According
to the measure, productive emotional processing occurs when an activated primary adap-
tive or maladaptive emotional scheme is being processed in a contactfully aware manner.
For the purposes of this study, only primary adaptive emotions were coded. Productive pro-
cessing is defined by seven criteria: attending, symbolization, congruence, acceptance, regu-
lation, agency, and differentiation. Attending refers to the client being aware of and
attending to their emotions and related attachment/identity needs and action tendencies.
Symbolization refers to the ability of the client to put their emotional experience into words
and to begin to label their emotional reactions and related attachment/identity needs. Con-
gruence refers to the match between the verbal expression of emotion and the nonverbal
expression of emotion (e.g., crying when speaking about loss, as opposed to smiling when
speaking about painful, traumatic events). Acceptance refers to the client exploring their
emotions and needs in an open and receptive manner, rather than interrupting their explo-
ration by criticizing themselves (“It’s so childish to expect her to protect me”), focusing on

www.FamilyProcess.org
TSVIELI ET AL. / 7
their discomfort about experiencing the feeling (“I’m such a whiner”), or changing the sub-
ject. Regulation refers to the client’s emotion scheme being sufficiently aroused without the
client becoming overwhelmed by their emotion, so that they maintain an ability to integrate
affect and an ability to reflect on their experience. Agency refers to the client acknowledging
and taking responsibility for the fact that their emotion is their own construction, and that
they are able to work through their emotions (in contrast to taking a victim stance and
blaming somebody else for how one feels). Finally, differentiation refers to clients’ emotional
experience becoming more complex over time, with new feelings or aspects of feelings
emerging. There is a sense that the emotion is more fully allowed, more freely expressed, or
that its expression changes (in contrast to the client remaining stuck in one single strong
emotional reaction, or being unable to go beyond a basic, vague symbolization of their emo-
tion, which reflects global distress; Auszra et al., 2010).
According to the scale, clients’ emotional expressions are assigned productivity scores
ranging from “0” = mixed/uncodable expressions, with no clear indicator of any of the dis-
tinct categories, to “4” = productive, when all the above specified criteria are met. In previ-
ous studies, employing both a three-level and five-level version of the scale, inter-rater
reliability was found to be very good and productivity scores were found to predict treat-
ment outcome (Auszra, Greenberg, & Herrmann, 2013; Greenberg et al., 2007). Because
in this study we were only interested in clearly productive moments of emotional process-
ing, we divided the scale into two categories: “clearly productive” (i.e., category “4”) and
“not clearly productive processing” (i.e., all other client utterances). Categorizing only
clearly productive instances of productive processing as such raised the threshold for what
is defined as productive processing, thereby increasing the internal validity of the study.
Also, in this study, productive emotional processing was measured at the level of speech
turns, and not in 1-minute segments as has been done in previous studies (Auszra et al.,
2013; Greenberg et al., 2007). Choosing speech turns as the unit of analysis allowed for
examining the moment-to-moment impact of each therapist intervention on adolescents’
immediately subsequent response, regardless of the duration of adolescents’ responses. In
a prior study in which productive emotional processing was also coded using this two-level
version of the scale, reliability was good (Tsvieli & Diamond, 2018). Each client’s speech
turn was coded separately, either as “productive emotional processing” (if it met all the
mentioned-above CEPS-R criteria), or as “no processing” (if it did not meet at least one of
the criteria). Instances of initiation of productive emotional processing were defined as cli-
ents’ speech turns that: (a) were coded as “productive emotional processing”; and (b) imme-
diately followed a previous “no processing” client speech turn. On the other hand,
instances of discontinuation of productive emotional processing were defined as clients’
speech turns that: (a) were coded as “no processing”; and (b) immediately followed a previ-
ous “productive emotional processing” client speech turn.
Finally, in this study, coders were also asked to not only identify when productive emo-
tional processing took place, but also whether such processing involved primary adaptive
vulnerable emotions (e.g., hurt, grief) or primary assertive anger (e.g., “I am angry that
you didn’t protect me better”). For a more thorough explanation regarding the distinction
between primary adaptive versus primary maladaptive and secondary emotions according
to emotion theory, see Auszra et al. (2010) and Pascual-Leone and Greenberg (2007).

Therapist interventions. Five of the interventions examined in this study were

drawn from the Therapeutic Behavior Rating Scale–3rd version (TBRS-3; Diamond,
Hogue, Diamond, & Siqueland, 1996). The TBRS-3 is an observer-based instrument
designed to measure the extent to which therapists employ each of 20 discrete therapist
interventions over the course of a therapy session. In previous research, coders were able
to reliably code the therapist interventions included on the scale, and the scale as a whole

Fam. Proc., Vol. x, xxxx, 2019

8 / FAMILY PROCESS

was found to discriminate between attachment-based family therapy, individual cogni-

tive-behavioral therapy, and MDFT (Diamond, Diamond, & Hogue, 2007).
The five TBRS-3 interventions used in this study included: (a) Focus on primary adap-
tive vulnerable emotions (e.g., “I can hear how painful this is for you”); (b) Relational
reframes, meant to shift the focus away from the events or dynamics associated with the
depressive and suicidal symptoms and onto the rupture/distance in the parent-adolescent
relationship (e.g., “So, even your mother doesn’t know how hard it is for you at school,” “It
sounds like when you are feeling really hopeless, you don’t feel like you can go to your par-
ents and you end up feeling all alone”); (c) Focus on core relational themes such as trust,
respect, independence, etc. (e.g., “It sounds like it’s not really about what time you come
home, but more about whether your father trusts your judgment”); (d) Psychoeducation
(e.g., “Parents sometimes struggle with finding the right balance between trying to protect
their child and recognizing that their child is no longer a kid”); and (e) Encourages affect
(generally; e.g., “I wonder what feelings come up for you when you are telling me this
story”).
This study also included five additional interventions developed in a previous study
(Tsvieli & Diamond, 2018): (f) Focus on unmet attachment/identity needs (e.g., “What did
you need from her in that moment?”); (g) Reassurance (e.g., “I know sharing your feelings
is difficult, but you are doing a great job”); (h) Interpretation (e.g., “I wonder if your not
answering the phone is a way to keep your distance”); (i) Focus on adaptive, assertive
anger (e.g., “I hear how angry you are at your father for not protecting you”); and (j) Focus
on secondary rejecting anger toward the parent (e.g., “I can see how resentful you are
toward your stepmother for being mean to you”).
In total, 10 therapist intervention categories were coded. Interventions were coded at
the level of speech turn. In cases in which the therapist employed multiple interventions
during a single speech turn, only the last intervention was coded. In a previous study
examining the same 10 interventions, and using the same procedure, inter-rater reliabil-
ity was very good (Tsvieli & Diamond, 2018). Therapist speech turns that were not reflec-
tive of any one of the above 10 interventions categories were coded as “other.” The other
category included interventions such as information gathering.

Procedure
Selecting sessions for analyses. On average, there were five individual alliance-
building sessions with the adolescent per case. Two individual alliance-building sessions
with the adolescent were randomly selected from each case and submitted for analyses.

Training productive emotional processing coders. Five independent coders were

trained to apply the Productivity Scale to identify clients’ speech turns reflecting produc-
tive emotional processing of primary adaptive emotions. Coders were undergraduate psy-
chology students, naive to the purpose of the study. The training consisted of five
meetings of three hours each, during which coders applied the measure to sessions not
included in the study.

Training therapist intervention coders. Two undergraduate psychology students

who were naive to both the study hypotheses and the productive emotional processing
scores were trained to code therapist interventions. The training consisted of three meet-
ings, lasting three hours each, during which coders practiced applying the measure to ses-
sions not included in the study.

Coding procedure. The coding of productive emotional processing and therapist

interventions were done separately. Pairs of productive emotional processing coders were

www.FamilyProcess.org
TSVIELI ET AL. / 9
assigned to sessions on the basis of random, rotating pairs. Each coder watched and coded
each videotaped session independently. In each selected session, all of the adolescent
speech turns were rated as either clearly productive or not clearly productive. In addition,
for those speech turns coded as clearly productive, coders also designated whether the
processing was of primary adaptive vulnerable emotion or assertive anger. In regard to
therapist interventions, the two therapist intervention coders rated all therapist speech
turns across all study sessions. Each intervention was assigned to one of the 10 interven-
tion categories or to the other category. In cases of disagreement between coders, the
primary investigator served as the third and decisive coder.

RESULTS
Preliminary Results
Reliability estimates of productive emotional processing coding. The inter-
rater reliability estimate for productive emotional processing codes was calculated using
Cohen’s kappa statistic (McHugh, 2012). The results produced a kappa of .85 (95% CI,
.82–.87, p < .001), which is considered substantial (Landis & Koch, 1977) and very good
(Cohen, 1960). In 28 of the 60 sessions that were selected for analyses, coders did not find
any client speech turns reflecting productive emotional processing. Consequently, only 32
of the selected sessions were included in the final analyses. Across these 32 selected ses-
sions, there were a total of 6,629 client speech turns. Of these, 242 speech turns were
deemed to reflect productive emotional processing.

Therapist effects on frequency of emotional processing. A chi-square analysis

was conducted to examine the association between therapist and frequency of adolescents’
productive emotional processing of primary adaptive emotions. This analysis yielded a sig-
nificant result (X2 (8, 6628) = 67.79, p < .001), suggesting that certain therapists were
more effective at facilitating productive emotional processing than others. Post hoc resid-
ual analysis (Delucchi, 1993) suggested that two of the nine therapists facilitated emo-
tional processing at rates higher than expected by chance (Adj. res = 4.13, p < .001 and
Adj. res = 5.03, p < .001, respectively), and that two other therapists facilitated productive
emotional processing at rates lower than expected by chance (Adj. res = 3.81, p < .001 and
Adj. res = 3.5, p < .001, respectively).

Reliability estimates of therapist intervention coding. In order to assess inter-

rater agreement between therapist intervention coders, a Cohen’s kappa was calculated.
The resulting kappa of .66 (95% CI, .65–.68, p < .001) is considered substantial (Landis &
Koch, 1977) and good (Cohen, 1960). Coders agreed regarding 6,611 of 6,863 interventions,
when including the “other” category. Since the great majority (81.5%) of therapist speech
turns were coded as “other”, and in order to avoid artificially inflating the reliability esti-
mate, a Cohen’s kappa was also calculated without including the other category. The
result was a kappa of .67 (95% CI, .65–.69, p < .001), which is substantial (Landis & Koch,
1977) and good (Cohen, 1960). Coders agreed regarding 1,208 interventions of 1,223 inter-
ventions not coded as “other.”
In addition, the rate of absolute agreement was calculated for each of the 10 therapist
intervention categories and the other category, separately. Since no therapist speech turns
were coded as Psychoeducation or Focus on core relational themes, these two categories
were excluded from all subsequent analyses. Rates of absolute agreement for the remain-
ing eight intervention categories and the other category ranged between 51% and 73%.

Fam. Proc., Vol. x, xxxx, 2019

10 / FAMILY PROCESS

Frequency of each category of therapist intervention. The frequency at which

each intervention appeared, in percentages, were as follows: other (81.5%), encourages
affect (6.1%), relational reframes (5%), focus on primary adaptive vulnerable emotions
(3.4%), focus on rejecting anger toward the parent (1.8%), focus on unmet attachment/
identity needs (0.8%), interpretations (0.6%), focus on adaptive, assertive anger (0.5%),
and reassurances (0.3%).

Transitional Probabilities
In order to examine whether productive emotional processing of adaptive vulnerable
emotions and assertive anger were more likely to begin, or to be discontinued once they
had already begun, following each type of therapist intervention, transitional probabilities
were calculated. Transitional probabilities were computed by dividing the frequency of
productive emotional processing (B) by the total frequency of adolescents’ responses fol-
lowing a specific category of therapist intervention (A). Transitional probabilities were cal-
culated separately for the productive emotional processing of adaptive vulnerable
emotions and for the productive emotional processing of assertive anger.
Data were analyzed using the SEQUENTIAL syntax script from the SPSS program
(O’Connor, 1999). Due to the low base rate of emotional processing segments found in each
session, statistical power was insufficient to address the nested nature of the data (i.e.,
segments existed within clients). Therefore, as recommended by Bakeman and Gottman
(1997), data from all clients were pooled. To test the significance of each transition, z
scores were computed. In order to reduce the chance of Type I error due to multiple com-
parisons (i.e., alpha inflation), two methods recommended by Bakeman and Gottman
(1997) were applied. First, a Bonferroni correction was employed, with alpha values set at
p < .002 (.05/24). Second, for each comparison, Yule’s Q values were calculated in order to
evaluate the effect size. Since Yule’s Q values of .50 or higher reflect a substantial positive
association (Davis, 1971), only comparisons which yielded such an effect size were
reported. In order to control for the potential effect of autocorrelation (i.e., the possibility
that productive emotional processing was caused by the adolescent’s emotional processing
which had already begun in the previous speech turn), transitional probabilities for the
initiation of productive processing were examined only for instances in which productive
emotional processing was not present in the immediately prior adolescent speech turn.
The probability and frequency of the initiation and discontinuation of productive
emotional processing of primary vulnerable emotions and primary assertive anger follow-
ing each type of therapist intervention appear in Table 1.

Therapist interventions and the subsequent initiation of adolescents’ produc-

tive emotional processing of primary adaptive vulnerable emotions. In accor-
dance with the study’s hypotheses, therapists’ focus on primary adaptive vulnerable
emotions and relational reframe interventions were more likely than chance to be followed
by the initiation of adolescents’ productive emotional processing of adaptive vulnerable
emotions, with the transitional probability for focusing on primary adaptive vulnerable
emotions being .14 (p < .001, Yule’s Q = .95), and for relational reframe interventions
being .04 (p < .001, Yule’s Q = .80). In addition, therapists’ general focus on emotional
experience was more likely than chance to be followed by the initiation of adolescents’
productive emotional processing of vulnerable emotions, with the transitional probability
being .05 (p < .001, Yule’s Q = .85). Finally, the association between therapists’ focus on
unmet attachment/identity needs and the subsequent initiation of adolescents’ productive
emotional processing approached significance, with the transitional probability being
.04 (p < .01, Yule’s Q = .73).

www.FamilyProcess.org
 TSVIELI ET AL.

Fam. Proc., Vol. x, xxxx, 2019

TABLE 1
Probability and Frequency of the Initiation and Discontinuation of Productive Emotional Processing of Primary Adaptive Emotions After Each Category of
Therapist Interventions

Emotional Encourages Vulnerable Attachment Assertive Rejecting Relational

processing affect emotions needs anger anger Interpretation Reassurance reframe

Initiation-vulnerable .06*** (23) .14*** (32) .04** (2) .00 (0) .00 (0) .02 (1) .00 (0) .04*** (15)
emotions
Initiation-assertive .00 (2) .00 (0) .00 (0) .21*** (7) .00 (0) .02 (1) .00 (1) .00 (1)
anger
Discontinuation .02*** (10) .01 (3) .06*** (3) .00 (1) .06*** (8) .05*** (2) .09*** (2) .01 (3)

Note. **p < .01, Yule’s Q > .50. ***p < .001, Yule’s Q > .70.
/ 11
12 / FAMILY PROCESS

Therapist interventions and the subsequent initiation of adolescents’ produc-

tive emotional processing of assertive anger. In accordance with the study’s hypothe-
ses, therapist’s focus on assertive anger was more likely than chance to be followed by
the initiation of adolescent’s productive emotional processing of assertive anger, with the
transitional probability being .21 (p < .001, Yule’s Q = .99).

Therapist interventions and the subsequent discontinuation of adolescents’

productive emotional processing of primary adaptive emotions. In accordance
with the study’s hypotheses, therapists’ focus on rejecting anger toward a parent, interpre-
tations, reassurances, and general focus on adolescents’ emotional experience were all
more likely than chance to be followed by the discontinuation of adolescents’ productive
emotional processing once it had already begun, with the transitional probabilities being
.06 (p < .001, Yule’s Q = .84); .05 (p < .001, Yule’s Q = .76); .09 (p < .001, Yule’s Q = .87);
and .02 (p < .001, Yule’s Q = .61), respectively. Contrary to expectations, therapists’ focus
on attachment/identity needs was also more likely than chance to be followed by the dis-
continuation of adolescents’ productive emotional processing once it had already begun,
with the transitional probability being .06 (p < .001, Yule’s Q = .80).
In order to rule out the possibility that the above reported effects were accounted for by
therapist effects, the same analyses were conducted once more, this time without includ-
ing data from the cases of the two therapists who were found to be significantly more effec-
tive than the others in facilitating productive emotional processing. Even after removing
these therapists, the findings remained the same.

DISCUSSION
This study was the first to examine the efficacy of specific therapist interventions in
terms of facilitating the productive emotional processing of primary adaptive emotions
among depressed and suicidal adolescents receiving attachment-based family therapy. As
hypothesized, and in accordance with ABFT theory and practice (Diamond, 2014; Dia-
mond et al., 2014), therapists’ focus on primary adaptive vulnerable emotions, therapists’
focus on unmet attachment/identity needs, and relational reframe interventions were all
found to immediately precede the initiation of adolescents’ productive emotional process-
ing of adaptive vulnerable emotions at a rate greater than chance. In regard to the produc-
tive processing of assertive anger, only therapists’ focus on assertive anger was found to
immediately precede the initiation of such processing at a rate greater than chance. These
findings provide the first empirical evidence suggesting that specific emotion- and attach-
ment-focused interventions indeed facilitate productive emotional processing of primary
adaptive emotions among this sample of highly distressed and often under-regulated or
disengaged adolescents. This is important because, while helping such adolescents access
and connect to their adaptive vulnerable emotions and assertive anger allows them to
make sense of their own experience, and guides them interpersonally, in terms of how to
express and get their needs met in a healthy, effective manner, such processing can be
challenging with this population.
Our results are consistent with findings from previous research conducted on other
emotion-focused and experiential therapies and clinical populations. For example, a num-
ber of studies with adults have found that therapist interventions such as reflecting pri-
mary emotions, evocative responding, heightening, and helping clients engage in an
episodic memory of a problematic episode, measured at the session level, were associated
with deeper client experiencing and productive emotional processing (Greenberg, 2010;
Greenberg & Clarke, 1979; Greenberg & Watson, 1998; Zuccarini, Johnson, Dalgleish, &
Makinen, 2013). Our results also partially replicate results from a prior study conducted

www.FamilyProcess.org
TSVIELI ET AL. / 13
on ABFT for young adults with unresolved anger, which found that focusing on vulnerable
emotions, and focusing on unmet attachment/identity needs, facilitated the subsequent
initiation of young adults’ productive emotional processing of primary adaptive emotions
(Tsvieli & Diamond, 2018). However, unlike the previous study on angry young adults,
and in accordance with our hypothesis, in this study of depressed and suicidal adolescents,
relational reframe interventions did lead to the initiation of productive emotional process-
ing. As expected, shifting these adolescents’ attention to the rupture in their relationship
with parents elicited and amplified the adaptive sadness associated with being alone with
their depression and suicidal ideation. In contrast, with young adults suffering from unre-
solved anger toward a parent, shifting their attention to the rupture in their relationship
with parents tends to activate their dominant emotion of rejecting, blaming anger. For
individuals presenting with high levels of secondary anger, directly focusing on vulnerable
emotions may be required to facilitate productive processing.
As expected, our findings also showed that certain interventions were associated with
the discontinuation of adolescents’ productive emotional processing of primary adaptive
emotions once it had begun. Specifically, therapists’ focus on adolescents’ rejecting anger
toward their parents, therapists’ general encouragement of affect, interpretations, and reas-
surance were found to be associated with the subsequent discontinuation of adolescents’
productive emotional processing. These various interventions likely interrupted productive
emotional processing in different ways. Whereas therapists’ focus on rejecting anger, by def-
inition, encouraged adolescents to attend to their secondary emotions, interventions such as
reassurance and interpretations required adolescents to stepback, reflect, and analyze. For
example, reassurance interventions (e.g., “It’s O.K. to cry,” “It’s not easy to speak about
these things—you are doing a great job”) likely shifted adolescents’ attention away from
their emotional experience in the moment and, instead, onto the process of the therapy and
more abstract constructs such as their meta-emotions (i.e., emotions and beliefs about feel-
ing and expressing certain emotions; Gottman et al., 2013). Such interventions, which
enlist more cognitive-analytic effort, likely lead to the momentary downregulation of emo-
tions. Our results are consistent with prior research showing that therapists’ focus on
rejecting anger was followed by the discontinuation of productive emotional processing that
had already begun in the context of ABFT for unresolved anger (Tsvieli & Diamond, 2018),
and with research suggesting that therapist interventions such as questioning, highlighting
non-emotional content (Wiser & Goldfried, 1998), and using cognitive language during high
affect segments (Anderson et al., 1999), were associated with shifts to low levels of experi-
encing and poor treatment outcome.
Surprisingly, not only was therapists’ focus on unmet attachment/identity needs fol-
lowed by the initiation of adolescents’ productive processing of primary adaptive emotions,
as hypothesized, but it also preceded the discontinuation of adolescents’ productive emo-
tional processing once it had already begun. One possible explanation is that, while focus-
ing on unmet attachment/identity needs may serve to activate emotion schema and elicit
associated adaptive vulnerable emotions, once the processing of such emotions has already
begun, focusing on specific unmet attachment/identity needs may actually distance the
adolescent from their immediate emotional experience. For example, asking an adolescent
who has already come into contact with feeling sad and abandoned, “What do you need
from your parents when you are sad?”, may lead him/her to respond by focusing on con-
crete needs (e.g., “I need them to tell my siblings to leave me alone”), on secondary emo-
tions such as hopelessness (e.g., “There’s really nothing they can do”), or on defensive
avoidance (e.g., “I don’t really need them”), rather than continue to simply experience
their adaptive hurt.
Another surprising finding was that therapists’ general encouragement of affect was
not only associated with the discontinuation of productive emotional processing once it

Fam. Proc., Vol. x, xxxx, 2019

14 / FAMILY PROCESS

had begun, as hypothesized, but also with the initiation of productive emotional process-
ing of adaptive vulnerable emotions. It may have been that, in the context of complex
sequences of therapist interventions, which included interventions specifically focused on
eliciting adolescents’ adaptive vulnerable emotions (e.g., relational reframes, therapists’
focus on unmet attachment/identity needs), generally encouraging affect also served to
facilitate the processing of previously avoided adaptive vulnerable emotions. Such com-
plex sequences of interventions are worthy of study.
Of note is the seemingly low rate of adolescents’ productive emotional processing of pri-
mary adaptive emotions in this study. Almost half of the individual alliance-building ses-
sions with these adolescents contained no productive emotional processing. Moreover, in
the 32 sessions that did contain productive emotional processing, only 3.7% of adolescent
speech turns evidenced such processing. However, these findings are consistent with find-
ings from previous studies of productive emotional processing. For example, Kramer and
colleagues, using the Classification of Affective Meaning States observer-rating system
(Pascual-Leone & Greenberg, 2005), found an average of only five minutes of grief/hurt
and assertive anger in sessions of short-term psychodynamic therapy with college stu-
dents suffering from adjustment disorders with depressed mood (Kramer et al., 2015),
though the presence of only one minute of adaptive grief was sufficient to distinguish
between good and poor outcome cases. Likewise, Diamond et al. (2016), using the Produc-
tivity Scale to examine productive emotional processing of primary adaptive emotions in
ABFT and individual EFT for young adults suffering from unresolved anger toward a par-
ent, found an average of less than one minute of productive emotional processing across
two sessions from each case, though the amount of productive processing still predicted
changes in psychological symptoms across both treatments. Together, these findings sug-
gest that, while moments of productive emotional processing of adaptive emotions are
infrequent, they are clinically meaningful, emphasizing the need to develop and test inter-
ventions that facilitate such processing.
Confidence in our findings is bolstered by a number of methodological strengths of the
study. First, the number of cases analyzed was considerable and larger than in most pro-
cess studies of this nature. A total of 242 instances of emotional processing were analyzed.
Also, the validity of these findings was increased by the fact that analyses were conducted
on actual ABFT sessions with adolescents meeting rigorous criteria for clinical levels of
depressive and suicidal symptoms. With that said, this study also has some clear limita-
tions. First, findings related to assertive anger were based on a relatively small number of
instances. Only 26 of the 242 instances of productive emotional processing involved asser-
tive anger. This may have been because ABFT therapists tended to focus more on adaptive
vulnerable emotions than on assertive anger. Indeed, only 0.5% of all therapist interven-
tions focused on adolescents’ assertive anger compared to 3.4% which focused on adoles-
cents’ adaptive vulnerable emotions. Further research with more instances of assertive
anger is required to adequately explore potential links between specific therapist inter-
ventions and clients’ productive processing of assertive anger. Second, this study only
examined the immediate effects of therapist interventions. It is possible that the impact of
the interventions examined was delayed. Finally, the impact of a given intervention may
be predicated on previous interventions. Larger datasets with more instances of produc-
tive emotional processing would allow for the analysis of both lagged effects and complex
sequences of therapist interventions.
Even in light of these limitations, the results of this study provide the first empirical
evidence supporting the role of emotion-focused and attachment-focused interventions in
promoting productive emotional processing of primary adaptive emotions among
depressed and suicidal adolescents receiving ABFT. Moreover, such interventions seem to
be more effective at promoting productive emotional processing than other, more

www.FamilyProcess.org
TSVIELI ET AL. / 15
cognitive, general, or abstract interventions, which may lead to the discontinuation of pro-
ductive processing once it has begun. It should be noted, however, that while emotion- and
attachment-focused interventions may be effective in terms of activating emotions and ini-
tiating productive processing, interventions such as reassurance can be helpful in terms of
sustaining such processing once it has begun. Indeed, ABFT therapists often use reassur-
ance, and other interventions, to help adolescents downregulate in order to avoid feeling
overwhelmed and remain connected to their adaptive emotions. It is also important to
remember that productive emotional processing is not an end in and of itself in ABFT.
Instead, productive emotional processing is one step in the overall treatment process. In
ABFT, therapists first focus on facilitating adolescents’ productive emotional processing of
adaptive emotions so that such emotions and associated unmet attachment and identity
needs are available and sufficiently articulated for the adolescent. Then, therapists move
on to the next step of helping the adolescent to express their adaptive emotions and needs
to their parents, in a connected and regulated manner, during subsequent conjoint attach-
ment/identity episodes. This two-step process is essential for promoting healthier attach-
ment relationships. In light of the importance of productive emotional processing in
ABFT, these findings have clear implications for therapist training and model develop-
ment. They also may have implications across a wide range of therapies in which emo-
tional processing is a purported primary change mechanism (e.g., Diener & Hilsenroth,
2009; Foa, Huppert, & Cahill, 2006; Greenberg, 2002).

REFERENCES
Adam, K. S., Sheldon-Keller, A. E., & West, M. (1996). Attachment organization and history of suicidal behavior
in clinical adolescents. Journal of Consulting and Clinical Psychology, 64(2), 264–272. https://doi.org/10.1037/
0022-006X.64.2.264.
Allen, J. P., Porter, M., McFarland, C., McElhaney, K. B., & Marsh, P. (2007). The relation of attachment security
to adolescents’ paternal and peer relationships, depression, and externalizing behavior. Child Development,
78(4), 1222–1239. https://doi.org/10.1111/j.1467-8624.2007.01062.x.
Anderson, T., Bein, E., Pinnell, B., & Strupp, H. (1999). Linguistic analysis of affective speech in psychotherapy:
A case grammar approach. Psychotherapy Research, 9(1), 88–99. https://doi.org/10.1080/
10503309912331332611.
Auszra, L., Greenberg, L. S., & Herrmann, I. (2013). Client emotional productivity – Optimal client in-session
emotional processing in experiential therapy. Psychotherapy Research, 23(6), 732–746. https://doi.org/10.1080/
10503307.2013.816882.
Auszra, L., Greenberg, L. S., & Herrmann, I. R. (2010). Client emotional productivity scale revised (CEPS-R). Tor-
onto, ON: York Psychotherapy Research Clinic.
Avenevoli, S., Swendsen, J., He, J. P., Burstein, M., & Merikangas, K. R. (2015). Major depression in the National
Comorbidity Survey-Adolescent Supplement: Prevalence, correlates, and treatment. Journal of the American
Academy of Child and Adolescent Psychiatry, 54(1), 37–44. https://doi.org/10.1016/j.jaac.2014.10.010.
Bakeman, R., & Gottman, J. M. (1997). Observing interaction: An introduction to sequential analysis (2nd ed.).
New York: Cambridge University Press.
Becker-Weidman, E. G., Jacobs, R. H., Reinecke, M. A., Silva, S. G., & March, J. S. (2010). Social problem-solving
among adolescents treated for depression. Behaviour Research and Therapy, 48(1), 11–18. https://doi.org/10.
1016/j.brat.2009.08.006.
Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). New York: Basic Books.
Chiu, Y. C., Tseng, C. Y., & Lin, F. G. (2017). Gender differences and stage-specific influence of parent–adolescent
conflicts on adolescent suicidal ideation. Psychiatry Research, 255, 424–431. https://doi.org/10.1016/j.psychres.
2017.06.077.
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20
(1), 37–46. https://doi.org/10.1177/001316446002000104.
Davis, J. A. (1971). Elementary survey analysis. Englewood Cliffs, NJ: Prentice-Hall.
Delucchi, K. L. (1993). On the use and misuse of chi-square. In G. Keren & C. Lewis (Eds.), A handbook for data
analysis in the behavioral sciences (pp. 294–319). Hillsdale, NJ: Lawrence Erlbaum.
Diamond, G. M. (2014). Attachment-based family therapy interventions. Psychotherapy, 51(1), 15–19. https://doi.
org/10.1037/a0032689.

Fam. Proc., Vol. x, xxxx, 2019

16 / FAMILY PROCESS

Diamond, G. M., Diamond, G. S., & Hogue, A. (2007). Attachment-based family therapy: Adherence and differen-
tiation. Journal of Marital and Family Therapy, 33(2), 177–191. https://doi.org/10.1111/j.1752-0606.2007.
00015.x.
Diamond, G. M., Hogue, A., Diamond, G. S., & Siqueland, L. (1996). Scoring manual for the Therapist Behavior
Rating Scale- 3rd Edition (TBRS-3). Unpublished manuscript. Philadelphia, PA: Center for Family Interven-
tion Science.
Diamond, G. M., Rochman, D., & Amir, O. (2010). Arousing primary vulnerable emotions in the context of unre-
solved anger: “Speaking about” versus “speaking to”. Journal of Counseling Psychology, 57(4), 402–410.
https://doi.org/10.1037/a0021115.
Diamond, G. M., Shahar, B., Sabo, D., & Tsvieli, N. (2016). Attachment-based family therapy and emotion-
focused therapy for unresolved anger: The role of productive emotional processing. Psychotherapy, 53(1), 34–
44. https://doi.org/10.1037/pst0000025.
Diamond, G. M., & Siqueland, L. (1998). Emotions, attachment, and the relational reframe: The first session.
Journal of Systemic Therapies, 17(2), 36–50. https://doi.org/10.1521/jsyt.1998.17.2.36.
Diamond, G. S., Diamond, G. M., & Levy, S. (2014). Attachment-based family therapy. Washington, DC: American
Psychological Association. https://doi.org/10.1037/14296-000.
Diamond, G. S., Kobak, R. R., Ewing, E. S. K., Levy, S. A., Herres, J. L., Russon, J. M. et al. (in press). A random-
ized-controlled trial: Attachment-based family and nondirective supportive treatments for suicidal youth.
Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2018.10.
006.
Diamond, G. S., & Liddle, H. A. (1999). Transforming negative parent-adolescent interactions: From impasse to
dialogue. Family Process, 38(1), 5–26. https://doi.org/10.1111/j.1545-5300.1999.00005.x.
Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-based family therapy
for depressed adolescents: A treatment development study. Journal of the American Academy of Child and
Adolescent Psychiatry, 41(10), 1190–1196. https://doi.org/10.1097/00004583-200210000-00008.
Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K. et al. (2010). Attach-
ment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. Journal of
the American Academy of Child and Adolescent Psychiatry, 49(2), 122–131. https://doi.org/10.1016/j.jaac.2009.
11.002.
Diener, M. J., & Hilsenroth, M. J. (2009). Affect-focused techniques in psychodynamic psychotherapy. In R. A.
Levy & J. S. Ablon (Eds.), Handbook of evidence-based psychodynamic psychotherapy (pp. 227–247). Totowa,
NJ: Humana Press. https://doi.org/10.1007/978-1-59745-444-5_10.
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum
(Ed.), The nature and treatment of pathological anxiety (pp. 3–24). New York: Guilford Press.
Goschin, S., Briggs, J., Blanco-Lutzen, S., Cohen, L. J., & Galynker, I. (2013). Parental affectionless control and
suicidality. Journal of Affective Disorders, 151(1), 1–6. https://doi.org/10.1016/j.jad.2013.05.096.
Gottman, J. M., Katz, L. F., & Hooven, C. (2013). Meta-emotion: How families communicate emotionally.
Mahwah, NJ: Lawrence Erlbaum.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington,
DC: American Psychological Association. https://doi.org/10.1037/14692-000.
Greenberg, L. S. (2004). Emotion–focused therapy. Clinical Psychology and Psychotherapy, 11(1), 3–16. https://d
oi.org/10.1002/cpp.388.
Greenberg, L. S. (2010). Emotion-focused therapy: A clinical synthesis. Focus, 8(1), 32–42. https://doi.org/10.
1176/foc.8.1.foc32.
Greenberg, L. S. (2012). Emotions, the great captains of our lives: Their role in the process of change in psy-
chotherapy. American Psychologist, 67(8), 697–707. https://doi.org/10.1037/a0029858.
Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The relationship among emotional productivity, emotional
arousal and outcome in experiential therapy of depression. Psychotherapy Research, 17(4), 482–493. https://d
oi.org/10.1080/10503300600977800.
Greenberg, L. S., & Clarke, K. M. (1979). Differential effects of the two-chair experiment and empathic reflections
at a conflict marker. Journal of Counseling Psychology, 26(1), 1–8. https://doi.org/10.1037/0022-0167.26.1.1.
Greenberg, L., & Watson, J. (1998). Experiential therapy of depression: Differential effects of client-centered rela-
tionship conditions and process experiential interventions. Psychotherapy Research, 8(2), 210–224. https://doi.
org/10.1080/10503309812331332317.
Hasking, P. A., Coric, S. J., Swannell, S., Martin, G., Thompson, H. K., & Frost, A. D. (2010). Brief report: Emo-
tion regulation and coping as moderators in the relationship between personality and self-injury. Journal of
Adolescence, 33(5), 767–773. https://doi.org/10.1016/j.adolescence.2009.12.006.
Hershenberg, R., Davila, J., Yoneda, A., Starr, L. R., Miller, M. R., Stroud, C. B. et al. (2011). What I like about
you: The association between adolescent attachment security and emotional behavior in a relationship pro-
moting context. Journal of Adolescence, 34(5), 1017–1024. https://doi.org/10.1016/j.adolescence.2010.11.006.

www.FamilyProcess.org
TSVIELI ET AL. / 17
Kobak, R., & Bosmans, G. (2018). Attachment and psychopathology: A dynamic model of the insecure cycle. Cur-
rent Opinion in Psychology, 25, 76–80. https://doi.org/10.1016/j.copsyc.2018.02.018.
Kobak, R., & Duemmler, S. (1994). Attachment and conversation: Toward a discourse analysis of adolescent and
adult security. In K. Bartholomew & D. Perlman (Eds.), Attachment processes in adulthood. Advances in per-
sonal relationships (Vol. 5, pp. 121–149). London, UK: Jessica Kingsley Publishers.
Kramer, U., Pascual-Leone, A., Despland, J. N., & de Roten, Y. (2015). One minute of grief: Emotional processing
in short-term dynamic psychotherapy for adjustment disorder. Journal of Consulting and Clinical Psychology,
83(1), 187–198. https://doi.org/10.1037/a0037979.
Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33
(1), 159–174. https://doi.org/10.2307/2529310.
Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S., Barrett, K., & Tejeda, M. (2001). Multidimensional family
therapy for adolescent drug abuse: Results of a randomized clinical trial. The American Journal of Drug and
Alcohol Abuse, 27(4), 651–688.
McHugh, M. L. (2012). Interrater reliability: The kappa statistic. Biochemia Medica, 22(3), 276–282.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Minuchin, S., & Fishman, C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press.
Narkiss-Guez, T., Enav Zichor, Y., Guez, J., & Diamond, G. M. (2015). Intensifying attachment-related sadness
and decreasing anger intensity among individuals suffering from unresolved anger: The role of relational
reframe followed by empty chair interventions. Counselling Psychology Quarterly, 28(1), 44–56. https://doi.
org/10.1080/09515070.2014.924480.
Nelemans, S. A., Hale, W. W., Branje, S. J., Hawk, S. T., & Meeus, W. H. (2014). Maternal criticism and adoles-
cent depressive and generalized anxiety disorder symptoms: A 6-year longitudinal community study. Journal
of Abnormal Child Psychology, 42(5), 755–766. https://doi.org/10.1007/s10802-013-9817-x.
Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M. et al. (2013). Preva-
lence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National
Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70(3), 300–310. https://doi.org/10.
1001/2013.jamapsychiatry.55.
O’Connor, B. P. (1999). Simple and flexible SAS and SPSS programs for analyzing lag sequential categorical data.
Behavior Research Methods, Instruments, and Computers, 31(4), 718–726. https://doi.org/10.3758/
BF03200753.
Pascual-Leone, A., & Greenberg, L. (2005). Classification of affective meaning states. In A. Pascual-Leone (Ed.),
Emotional processing in the therapeutic hour: Why “the only way out is through” (pp. 289–367). Unpublished
doctoral thesis. Toronto, ON: York University.
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy: Why “the only way
out is through”. Journal of Consulting and Clinical Psychology, 75(6), 875–887. https://doi.org/10.1037/0022-
006X.75.6.875.
Safran, J. D., & Greenberg, L. S. (1991). Emotion, psychotherapy, and change. New York: Guilford Press.
Sentse, M., Lindenberg, S., Omvlee, A., Ormel, J., & Veenstra, R. (2010). Rejection and acceptance across con-
texts: Parents and peers as risks and buffers for early adolescent psychopathology. The TRAILS study. Jour-
nal of Abnormal Child Psychology, 38(1), 119–130. https://doi.org/10.1007/s10802-009-9351-z.
Sheeber, L., Hops, H., & Davis, B. (2001). Family processes in adolescent depression. Clinical Child and Family
Psychology Review, 4(1), 19–35. https://doi.org/10.1023/A:1009524626436.
Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M. et al. (2018). Vital signs: Trends
in state suicide rates—United States, 1999–2016 and circumstances contributing to suicide—27 states, 2015.
Morbidity and Mortality Weekly Report, 67(22), 617–624. https://doi.org/10.15585/mmwr.mm6722a1.
Tamas, Z., Kovacs, M., Gentzler, A. L., Tepper, P., Gadoros, J., Kiss, E. et al. (2007). The relations of tempera-
ment and emotion self-regulation with suicidal behaviors in a clinical sample of depressed children in Hun-
gary. Journal of Abnormal Child Psychology, 35(4), 640–652. https://doi.org/10.1007/s10802-007-9119-2.
Tsvieli, N., & Diamond, G. M. (2018). Therapist interventions and emotional processing in attachment-based fam-
ily therapy for unresolved anger. Psychotherapy, 55(3), 289–297. https://doi.org/10.1037/pst0000158.
Wiser, S., & Goldfried, M. R. (1998). Therapist interventions and client emotional experiencing in expert psycho-
dynamic–interpersonal and cognitive–behavioral therapies. Journal of Consulting and Clinical Psychology,
66(4), 634–640.
Zuccarini, D., Johnson, S. M., Dalgleish, T. L., & Makinen, J. A. (2013). Forgiveness and reconciliation in emo-
tionally focused therapy for couples: The client change process and therapist interventions. Journal of Marital
and Family Therapy, 39(2), 148–162. https://doi.org/10.1111/j.1752-0606.2012.00287.x.

Fam. Proc., Vol. x, xxxx, 2019