Australian and New Zealand Journal of Family Therapy 2016, 37, 190–206

doi: 10.1002/anzf.1151

Attachment-Based Family Therapy for

Suicidal Lesbian, Gay, and Bisexual
Adolescents: A Case Study
Suzanne A. Levy1*, Jody Russon1, and Gary M. Diamond2*
1 Center for Family Intervention Science, Drexel University, Philadelphia
2 Ben-Gurion University, Be’er Sheva

The majority of sexual minority adolescents are well-adjusted and healthy, however, on average, 28% report suici-
dal ideation and between 15% and 40% make a suicide attempt each year. These rates are two to seven times
higher than those found among heterosexual youths. Research has shown the protective function of parental sup-
port and acceptance, as well as the deleterious effects of parental criticism, invalidation, and rejection on the
mental health of sexual minority adolescents. Given these risk and protective factors, these adolescents might
benefit from an intervention that targets family relationships. Toward this goal, Attachment-Based Family Therapy
(ABFT) specifically aims to improve the quality of adolescent–parent relationships. In prior treatment developmen-
tal work, ABFT was adapted and pilot tested for depressed and suicidal lesbian, gay, and bisexual (LGB) adoles-
cents. By adopting an evidence-based case study format, this paper provides a case summary to illustrate how
the therapy was conducted. The case study consists of a vignette, followed by therapy task descriptions and illus-
trative transcripts. Examples of key therapeutic moments in ABFT, for depressed and suicidal LGB adolescents,
are discussed in the context of the case.

Keywords: adolescents, LGB, Attachment-Based Family Therapy, case study, suicide, depression

Key Points

1 Lesbian, gay, and bisexual (LGB) adolescents are at a higher risk of suicidal ideation and attempting suicide
compared to their heterosexual peers.
2 Parental criticism, invalidation, and rejecting messages toward LGB identities can negate protective mecha-
nisms associated with parental support.
3 A case study is used to illustrate the adaptations made to Attachment-Based Family Therapy (ABFT) for
use with LGB suicidal youth and their families.
4 ABFT for LGB youth involves identifying how destructive emotions and behaviours associated with parental
non-acceptance have compromised the parent–child relationship and the child’s wellbeing, and then helping
the family address and resolve these issues.

Lesbian, gay, and bisexual (LGB) youth are particularly at risk for reporting suicidal
ideation and making suicide attempts compared to their heterosexual peers (Haas
et al., 2011). While the majority of sexual minority adolescents are well-adjusted and
healthy (Savin-Williams, 2006), approximately 28% of these youths report symptoms
of suicidality (defined as ideation, plans or intent, and attempts; Marshal et al.,

*Address for correspondence: Suzanne A. Levy, Ph.D., Center for Family Intervention Science,
Drexel University, 3020 Market St., Suite 510, Philadelphia, PA 19104, USA. slevy@drexel.edu
Gary M. Diamond, Ph.D., Dept. of Psychology, Ben-Gurion University of the Negev, P.O.B. 653,
Beer-Sheva, Israel. gdiamond@bgu.ac.il

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 Suicidal LGB Adolescents

2011). Furthermore, between 15% and 40% make a suicide attempt each year – rates
which are two to seven times higher than their heterosexual counterparts (Haas et al.,
2011). Most researchers and clinicians agree that there is nothing inherently suicidal
about a same-gender sexual orientation. Instead, it is likely that negative environmen-
tal responses such as discrimination, victimisation, and rejection lead to social isola-
tion, anxiety, low self-esteem, depression, hopelessness, and helplessness, which, in
turn, lead LGB adolescents to contemplate killing themselves (Savin-Williams &
Ream, 2003).
One prominent risk factor for these youth is parental rejection of their sexual
orientation. Research on LGB adolescents suggests that over half of parents ini-
tially react to their child’s disclosure with some degree of negativity (D’Augelli,
Grossman, Starks, & Sinclair, 2010; Heatherington & Lavner, 2008; Samarova,
Shilo, & Diamond, 2014), exhibiting disappointment, anger, shock, and/or guilt
(Robinson, Walters, & Skeen, 1989). In some cases, parents may deny or explic-
itly disapprove of their child’s same-sex attractions, humiliate, threaten, or even
physically attack their child, as well as eject their child from the home (Hammel-
man, 1993; Hunter & Schaecher, 1987; Savin-Williams, 1989, 1994). In other
instances, disapproval and invalidation may be subtler and expressed via uncon-
scious or unintentional communications. Such subtle disapproving comments, facial
expressions, or behaviours have been termed ‘micro aggressions’ (Nadal et al.,
2011; Sue et al., 2007).
Parental criticism, invalidation, and rejection of a child’s sexual orientation nega-
tively impact the adolescent in two ways. First, such messages from parents directly
convey that something is wrong with the adolescent (Goldfried & Goldfried, 2001),
increasing the likelihood that the child will perceive him/herself as bad, shameful, or
unlovable (Rohner, 2014). Second, parental rejection leaves adolescents without a sup-
portive attachment figure to turn to when they face LGB-related discrimination, vic-
timisation, and rejection from others, further putting them at risk for suicidal
ideation and behaviour.
In contrast, when parents accept their LGB adolescent, the adolescent is likely to
feel validated, safe, and secure. In the context of such relationships, parents are posi-
tioned to support, guide, and advocate for their child as he or she faces the challenges
of growing up with a minority sexual orientation. This is important, as parental sup-
port has been shown to moderate the negative effects of gay-related victimisation
(Evans, Hawton, & Rodham, 2004; Shilo, Antebi, & Mor, 2015). Indeed, LGB
young adults who reported that they came from highly accepting families were less
likely to have suicidal thoughts. They were also less likely to have made a suicide
attempt, and more likely to report higher self-esteem, social support, and general
health than their LGB peers who reported low acceptance from their families (Ryan
et al., 2010). Other studies suggest that the association between LGB orientation and
suicidal thoughts is at least partially mediated by parental support and connectedness
(Eisenberg & Resnick, 2006; Needham & Austin, 2010).
Given the deleterious effects of parental criticism, invalidation, and rejection, and
the protective function of parental support and acceptance in the lives of sexual
minority adolescents, Attachment-Based Family Therapy (ABFT) (Diamond, Dia-
mond, & Levy, 2014) is considered well suited to treat this population. In prior treat-
ment development work, Diamond et al. (2012) treated 10 suicidal and depressed
LGB adolescents who were living at home and were out of the closet. Adolescents

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

were recruited based on their sexual orientation and high levels of suicidal and depres-
sive symptoms. Inclusion was not based on degree of parental rejection; consequently,
the degree of parental rejection varied from case to case. The authors found that, for
those parents having a hard time accepting their child’s sexual orientation, therapists
needed to take more time with parents alone to help them to connect to, express, and
work through their thoughts and feelings about their child’s sexual orientation. These
feelings often included loss, anger, fear, and shame. In addition, the authors found
that it was often important to help parents: (1) reconcile their religious beliefs with
their child’s sexual orientation; (2) discuss and work through fears about disappoint-
ing, or being rejected by, their own family of origin or community; and (3) address
their concerns for their child’s welfare. Only after working through their own emo-
tions were parents able to empathise with, and become more attentive to, their child’s
struggles with suicidal ideation or other forms of psychological distress. These parents
were also able to attend to their child’s attachment concerns and issues regarding sex-
ual identity development and acceptance.
The authors also found that discussions about the meaning and process of ‘accep-
tance’ were important for both the adolescent and parents. For those adolescents
who expected immediate and complete acceptance by their parents, reframing accep-
tance as an ongoing process reduced frustration and improved adolescent–parent
interactions. Therapists validated the adolescent’s justified demands for parental
respect, validation, and safety, while also helping the adolescent recognise that it
would take time for their parents to feel more comfortable with their sexual orienta-
tion. Results from a small open trial of this adapted version of ABFT showed that it
was acceptable for this population and that, as a group, adolescents evidenced signifi-
cant decreases in suicidal ideation, depressive symptoms, and maternal attachment-
related anxiety and avoidance over the course of the treatment (Diamond et al.,
2012).
This paper provides a case example from the aforementioned open trial to illus-
trate how the therapy was conducted with this population. We adopted an evi-
denced-based case study format. The case summary consists of a vignette, followed
by task descriptions and illustrative transcripts. Examples of key therapeutic
moments in ABFT for LGB adolescents are discussed in the context of the case.
Dr Suzanne Levy was the therapist for this case. The family gave permission for
use of their information with names and information changed to protect the iden-
tity of clients.

Case Vignette
Adela (16 years old) is a black, bisexual adolescent who lived with her mother, Edith,
and younger siblings. The family was referred to the study from a local inpatient
adolescent unit after Adela was hospitalised due to severe suicidal ideation and
behaviours. At intake, Adela scored a 32 on the Suicide Ideation Questionnaire Junior
(SIQ-JR – weekly version; Reynolds, 1988) and a 34 on the Beck Depression Inven-
tory (BDI); Beck, Steer, & Brown, 1996). Both of these scores are in the high clinical
risk range. She also endorsed a 6.83 on the attachment-related avoidance subscale and
a 4.25 on the attachment-related anxiety subscale of the Experiences in Close Rela-
tionships-Relationship scale (ECR-RS; Fraley et al., 2006), where 7 represents the
most insecure range.

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 Suicidal LGB Adolescents

Adela and her mother attributed her distress to a number of circumstances in her
life. For instance, she had only intermittent contact with her father and thus felt
abandoned by him. Adela also reported having difficulties with school and peers.
Although very creative, athletic, and intelligent, Adela felt like she never fitted in with
peers at school. This experience was exacerbated by having to ‘start over’ and make
new friends every time they moved to a new city. The family underwent frequent
moves as a result of Edith’s prior military career and subsequent job changes. In addi-
tion, Adela reported that her mother had responded negatively to the disclosure of
her bisexual identity. Her mother responded with criticism, shaming, high levels of
anxiety, intrusive monitoring, and attempts to control her behaviour (e.g., block her
from going out with her bisexual boyfriend). Adela not only felt hurt, but also dis-
couraged from going to her mother for support, comfort, or advice to help cope with
life’s challenges.
Adela’s mother, Edith, a first-generation immigrant from the Caribbean, brought
her daughter to therapy because of concern for her daughter’s suicidal ideation and
depression, as well as her anger and susceptibility to ‘peer pressure.’ Edith reported a
family history of mental health challenges, having herself experienced trauma and
abuse as a child, and a history of domestic violence in her romantic relationships. She
reported being unhappy about her daughter’s sexual orientation, fearing it made her
more vulnerable to discrimination and sexually transmitted diseases. Edith grew up in
an extremely homophobic culture, where having an LGB identity was totally unac-
ceptable, if not dangerous. At the time of treatment, Edith was taking college courses,
raising not only Adela but her younger siblings, and working full-time. She was able
to successfully manage her household and took great pride in her independence and
self-sufficiency. She recently married her youngest child’s father, with whom Adela
got along well. Adela and Edith attended therapy sessions for 16 weeks.

Task I – Relational Reframe

The therapist began treatment by joining with Adela around her interests and
strengths. Edith eagerly joined in, commenting on how good Adela was at softball,
shopping, and art. She also commented on Adela’s sophisticated sense of style. The
conversation then moved to the problems fueling Adela’s distress. Adela felt like she
didn’t fit in with her peers at school, missed her father, and was frustrated by her
constant fighting with her mother. Adela felt that her mother was not accepting of
her sexual orientation and that she consequently became over-controlling about her
social life. Edith agreed that she worried about Adela’s ‘choice’ of sexual orientation
and feared it put her at risk for diseases and social ostracism.
After empathically exploring both Edith’s and Adela’s concerns, the therapist began
the relational reframing process. The therapist asked Edith and Adela if Adela ever
talked to her mother about the stressors in her life. When Adela said no, the therapist
asked why. Adela said things usually ended with an argument; mum usually lectured
and criticised her, which led her to feel frustrated and angry. Edith responded by blam-
ing Adela, saying that it was her fault for not communicating more clearly.
At this point, the therapist diverted Edith and Adela away from attacking and
defending and, instead, focused on the hurt and disappointment they were both feel-
ing. The therapist asked both Adela and Edith if this is what happened at home –
that, instead of hearing each other and working through problems, they both ended

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

up feeling frustrated and alone. The therapist reframed Edith’s criticism and control
as stemming from a deep love and concern for her daughter – a desire to protect her
daughter. The therapist amplified mum’s desire to help her daughter and empathised
with her disappointment that her attempts at protection and closeness were not work-
ing. The therapist also reframed Adela’s anger and withdrawal as reactions to her own
disappointment at her mother’s responses, and her depression and suicidal ideation as
expressions of her hopelessness about the possibility of change. The reframe served to
acknowledge both Edith’s and Adela’s frustration and anger, but focused them on
their mutual sadness about their emotional distance, and their longing to connect.
This shift made it possible to set relational repair as the initial focus of therapy.
Therapist: Look, I know things have been hard between you two. But if I could help
your mother learn to listen to you better, be interested in what you are going
through, and how you feel, instead of lecture or criticise, would you be interested in
working on this?
Adolescent: She can’t do that. I have tried in the past a million times and it always
ends up in a fight.
Therapist: Was there was ever a time when you and mum were close?
Adolescent: Yes, in 9th grade, before I came out to her as bisexual.
Mother: (with a tear in her eye) That is true. It used to be that she came to me about
everything, she told me everything that was going on with her – when other girls
were bothering her, whatever.
Therapist: Is that something that you both miss? That type of closeness?
Adolescent: (now also crying) Yes. Back then I just felt I could be myself with her. I
just felt really happy.
Therapist: (to Edith) I can see how much you love your daughter, and how
important the relationship is to both of you. If, somehow, I could help you two get
some of that closeness back, help Adela to once again share with you what is going
on with her, and help you make her feel heard and comforted, rather than have
things escalate into arguments or fights, would you both want that; to feel together,
instead of alone? To protect her without pushing her away?
Mother: Of course. That is what I am here for.
Therapist: Okay. That is what we will focus on initially in this therapy. I want to
help Adela to do a better job of communicating, so that you don’t have to guess
what is going on with her and what she needs. And, I am going to help you respond
in a way that makes her want to come to you to talk.
Although a bit reluctant, Adela agreed to the relational goal along with her
mother. She wanted to feel loved by her mother again but she was doubtful that
Edith could change. She did agree, however, to come to the next session and talk
with the therapist about her reservations. The therapist ended the session by instilling
some hope in the family by telling them, ‘There is so much love here between the
two of you. But it is buried under so much hurt. I’m confident that if you both put
the work in, you can get that closeness back.’

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Task I – Adolescent Alliance Building

In the adolescent alliance building task (Task II), the therapist focuses on getting to
know the adolescent better, understanding the depression, and discussing what gets in
the way of talking to parents. If things go well, the therapist also prepares the adoles-
cent to talk with his or her parents in the upcoming attachment task. With Adela,
Task II consisted of four sessions.
The therapist started the task by getting to know Adela better, including her sex-
ual identity development. The therapist explored Adela’s experience realising she was
bisexual, and her coming out process. Adela said it started in her pre-teen years, but
that it was never upsetting. Her friends had always been accepting, but her family
was always rejecting over her sexuality.
Next, the therapist explored Adela’s depression and suicidal feelings. Adela
described feeling abandoned by her father, fear related to witnessing domestic violence
between her mother and her partners, and the pain and isolation caused by her
mother’s rejection of her as bisexual. The first three sessions of Task II focused on
exploring these issues. The therapist listened to the story of these events and uncov-
ered previously avoided painful emotions associated with them. Accessing these pri-
mary emotions (e.g., sadness, hurt, etc.), helped Adela better understand what drove
her hopelessness and despair. It also helped her to put words to how her mother’s dis-
missive and critical responses caused such pain and led her to withdraw. Legitimising
these feelings also led her to realise her longing for her mother’s acceptance (e.g., ‘it
sounds like, inside, you really want your mother to care and to be able to comfort
you in a way that feels good’). If adolescents acknowledge and feel their pain and
longing for attachment, the therapist can then offer therapy as an opportunity to heal
that rupture.
In the following segment, the therapist helped Adela talk about her mother’s
responses to her sexuality, how these responses made her feel, and how they have
undermined her trust in her mother.
Therapist: Let’s talk about your sexuality. I know that has been a source of tension
between you and your mother. When you told your mum that you were bisexual,
that didn’t go over so well?
Adolescent: It wasn’t really that I told her, it was like . . . I was talking to a girl, like,
we weren’t really going out, but we were like flirting with each other or whatever.
And, I don’t know how but I was asleep and my mother woke me up and she was
like . . . um, I guess I don’t know my phone rang or something or she texted me or
something, and she just started yelling and she was like . . . I was half asleep so I
don’t really remember, I just remember she called me a lesbian and I was like, I’m
not a lesbian because I like boys and she was like, but you like girls and I was like
yeah, but I’m not a lesbian though. And then the next day she wouldn’t even talk to
me. She wouldn’t even look at me.
Therapist: Mm. That sounds really upsetting. What was that like for you?
Adolescent: (said with despair) I was like, um, I mean I really felt like oh, she’s
probably going to send me away now.
Therapist: You sound sad.

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

Adolescent: It’s what I expected. That’s why I didn’t tell her. When we lived in
California and we were sitting in a restaurant by a window it was me, her, and my
aunt and these two girls got out of a truck. One of them was dressed kind of boyish
and they were obviously a couple. And my mum was like, if you ever became a
lesbian, no one is going to love you. Maybe she was joking. I really don’t know. But
I mean, I was like, if I told her, she’s going to hate me. And then when she did find
out, she stopped talking to me for like two days. I’m like . . . this is exactly what I
expected.
Therapist: Wow that sounds horrible. I wonder if you felt rejected by her, sort of
abandoned by her because of who you are?
Adolescent: Yeah, that is right. Like she abandoned me. She wouldn’t even look at
me.
Therapist: That must have been awful.
Adolescent: It was awful, but that was just the start. She continues to make those
sorts of comments [i.e., homophobic] to this day.
Therapist: What is that like for you?
Adolescent: It’s awful. She doesn’t accept me for who I am.
Therapist: It’s almost like she’s rejected who you are.
Adolescent: That’s exactly it.
The therapist wanted Adela to connect with some primary emotions related to
these stories and used her coming out story to get her connected to her pain. The
therapist then helped Adela discuss the ongoing rejection and abandonment from her
mother. The therapist also used attachment words like ‘abandonment’ and ‘rejection’
to help Adela understand how these relational ruptures contributed to her anger,
hopelessness, and suicidal feelings. This helped Adela have a more coherent under-
standing of her experience, her emotions, and her distrust of her mother.
Adela went on to talk about feeling rejected by her father and grandmother. Both
dismissed her bisexuality merely as peer pressure from her friends. Adela also angrily
described how her mother would make fun of gay people and how she yelled and
cursed at Adela when she caught her talking to girls. Given her mother’s homopho-
bia, Adela just stopped bringing LGB friends home. As the conversation continued,
Adela felt a deeper sadness, but also an assertive anger – more entitled and empow-
ered rather than passive and suicidal. Adela knew she deserved to be loved by her
family regardless of her sexual orientation.
Therapist: (noticing that Adela is getting emotional) What is going on right now
inside?
Adolescent: I feel like she doesn’t like that part of me, she would like it better if I
were straight. But yeah, I am not, so whatever.
Therapist: So she says that to you. What does it feel like when she says that?
Adolescent: I get so irritated, I’m like, I’m not going to be straight. You can say it
all you want but I’m not ever gonna be straight again.

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Therapist: I can imagine that made you angry.

Adolescent: Yeah. I mean, I feel like she’s dealing with me being bisexual now. Like
we’re trying stuff like this [therapy] . . .We’ve never talked, and then one time . . . she
started on this big thing and she was yelling at me and cursing and she called me a
lesbian slut. I’m like ‘I’m not a lesbian’ and she’s like ‘You like girls, you’re a
lesbian.’ She said she was watching Dr. Phil, and he said there’s no such thing as
bisexuals, it’s just lesbians and straight. I’m like ‘No, I like both, I’m bi, that’s how it
is.’ She’s like ‘No you’re a lesbian.’
Therapist: You know, that is really unfair.
Adolescent: Yeah.
Therapist: What worries me is that when you feel criticised by your mum and she
devalues your bisexuality, it makes your suicidal thoughts worse.
Adolescent: (sighs and looks around) This is so much of who I am but she like, she’s
so much against it. She knows that it’s a big part of who I am, a huge part. I feel
like she’s so against it, like she’s trying to keep me from being who I am. It’s almost
like she’s suffocating me, like pushing me in this box that I don’t fit into. It is just
not fair.
Adela went on to discuss how her mother’s rejection of her bisexuality made her
feel alone, angry, rejected, and helpless. Unlike some other sexual minority adoles-
cents, she did not report feeling shame or guilt. Adela reported feeling pride in her
identity, and that she had a network of support, including a strong community of
bisexual individuals she knew outside of school. This made it all the more upsetting
that her mother could not accept her. She was bisexual and wanted her mother’s
recognition and support. She also wanted a mother she could talk to about romantic
and peer issues.
The therapist seized on this critical moment where Adela expressed both indigna-
tion and longing. Rather than turn to suicide, the therapist encouraged Adela to try
and work this through with her mother. The therapist also reinforced the importance
of directly expressing her hurt, disappointment, and desire to have her mother’s sup-
port as opposed to yelling and screaming out of anger. Sharing these feelings directly
with her mother would be her best chance at helping Edith understand the bind she
puts her, Adela, in (e.g., ‘I will only love you if you are straight!’). Finally, the thera-
pist emphasised that this is also the best chance for Adela to convey to her mother
the long-term consequences of this criticism and non-acceptance.
Adolescent: I mean I feel like . . . if she doesn’t accept that part of me like, all this
therapy is almost pointless because this is who I am, and if you’re going to be
criticising me my whole life because of this, then how are we going to have a
relationship? When I get older and I find someone and maybe you know I end up
with a girl, and maybe if it’s legal and we decide to get married, how am I supposed
to invite her to my wedding if she won’t accept that part of me?
Therapist: That is important feedback to give to your mother. She needs to
understand that this part of you is not going away. If she can’t love that part of you
then that’s really going to get in the way of your relationship. This might be gradual.
Some things however have to change today. She has to stop this derogatory, critical

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

tone. If she wants a relationship with you, which I think she does, she has to stop
that right away. But other things like her feeling comfortable with you having a
girlfriend or seeing you with a girlfriend might take more time and happen gradually.
Just think, it took a little time for you to be comfortable with your sexuality, it may
take her time as well. How do you feel about giving her some time to get more
comfortable?
In this exchange, the therapist does a number of important interventions. The
therapist differentiates between mother’s non-acceptance and mother’s hurtful
behaviour, and supports Adela’s right to not be verbally abused and to assertively set
some boundaries with her mother. Adela’s right to be protected and safe is immediate
and non-negotiable if her mother wants a relationship. At the same time, the therapist
shows empathy for the mother’s struggles and accepts that she may not be able to
fully accept, let alone affirm, Adela’s sexuality in the immediate future. The therapist
tries to help find a middle ground that can help mother and daughter begin to build
trust again.
Compared to the typical course of ABFT for depressed and suicidal adolescents,
Task II sessions are often extended for LGB adolescents given the complexity of the
issues. As demonstrated in the segments above, the therapist consistently validated the
adolescent’s sense of rejection and betrayal by her mother and her right to be pro-
tected from criticism. At the same time, the therapist helped Adela to connect with
underlying primary emotions and unmet attachment needs, and moved her toward
change behaviour (i.e., talking to her mum). The therapist served as a secure base for
Adela throughout this process, which helped Adela find the strength and courage to
speak to her mother.
In the remaining Task II session, the therapist prepared Adela for the upcoming
conversation; what she wanted to say, how she wanted to say it, and how to react if
her mother was negative or non-responsive. The therapist assured Adela that she
would not initiate conjoint sessions until she was sure that her mother was willing
and able to listen better, and that Adela’s welfare was foremost on the list of her
mother’s concerns.

Task III – Parent Alliance Building

The parent alliance building task (Task III) first helps parents understand how current
stressors and their own attachment history influence their parenting. Therapists use
this as leverage to activate parental caregiving instincts, thus motivating them to learn
some new attachment-promoting parenting skills. Once parents are motivated, the
therapist prepares them to use emotion-coaching skills to help their adolescent fully
share their experience during the subsequent attachment task. With non-accepting
parents of LGB adolescents, this often takes more time than working with parents of
heterosexual teens. Part of the work requires uncovering layers of shame, loss, guilt,
uncertainty, and fear about their child’s sexual identity.
In this case, exploring how Edith’s own history of trauma impacted upon her par-
enting was crucial. As a child, she was neglected and physically abused while living
with extended family before coming to the United States in middle childhood. As an
adult, she was the victim of domestic violence from a romantic partner. Given these
experiences, themes of safety were at the forefront of her concerns for Adela.

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Preoccupied with keeping her daughter physically safe, Edith did not attend well to
Adela’s emotional needs. Moreover, growing up in the Caribbean, Edith internalised
the homophobic and intolerant views her culture held toward same-sex attraction and
behaviour. In her hometown, people who were ‘out’ were often attacked, or worse.
When Edith found out that Adela was bisexual, this reactivated those attitudes and
fears. She also assumed that bisexual people have multiple romantic partners simulta-
neously and practice unsafe sex. Thus, Edith became quite concerned about sexually
transmitted diseases and other medical problems, worrying that Adela’s current bisex-
ual boyfriend (Eddie) was likely promiscuous and could potentially infect Adela. The
therapist began to help Edith specify and differentiate between her various concerns
about Adela’s sexuality. Helping parents move from talking about sexual orientation
in global terms to talking about specific aspects, implications, and fears often results
in parents recognising that their catastrophic fantasies are not necessarily reality-based.
Edith also expressed her doubt that bisexuality was even real. Many parents seem
confused or skeptical about the validity, stability, or causality of their child’s sexual
orientation, particularly a bisexual orientation. In part, we take a psycho-educational
approach to this challenge, but we also encourage parents and adolescents to explore
these topics in conversation together during the repairing attachment task. For exam-
ple, we encourage parents to ask their adolescent when they became aware of their
same-sex attraction, how they felt during that time, when they first told someone,
what went on inside when they were keeping it a secret, and types of discrimination
or victimisation they may have experienced. We coach parents to enter this conversa-
tion with curiosity and openness, and not with disbelief and defensiveness. In this
case, as we often do, the therapist also referred Edith to local PFLAG meetings.
In the next stage of the task, the therapist explored with Edith how her non-accep-
tance of Adela’s sexual orientation affected her parenting. Edith acknowledged that
she often criticised her daughter and tried to dissuade her from pursuing a bisexual
lifestyle. The therapist invited Edith to contemplate how her criticism impacted
Adela. The therapist reminded Edith how she felt when she was ridiculed while being
abused as a child. Drawing the parallel between Edith’s experience as a child, and
Adela’s current experience, helped Edith to finally understand how her words were
hurting Adela. Realising this, Edith became sad, helpless, and more empathic toward
her daughter.
Mother: Where is my choice in this?
Therapist: You mean having to accept her sexual interests?
Mother: Right. Like it is an ultimatum. Why can’t she just accept the fact that I
don’t like it. Why am I being forced to like it?
Therapist: I think that it is hard for many parents. I want to be absolutely clear –
this isn’t about getting you to ‘like it.’ You have a lot of feelings inside. Fear,
disappointment, loss, and perhaps even disgust (mother nods in agreement, beginning to
tear up). I don’t think these feelings are going to go away immediately and it will
take a while for you to feel more comfortable with this part of Adela. I think it is
okay to say that it is hard for you and that it will take time. The important thing is
to let her know that you think she is okay and that you love her. That you are
working on being more supportive, closer, and that you are committed to at least not
hurting her in the meantime.

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

Mother: And in the end, if it doesn’t work out in her favour, if I try and I still really
can’t . . . (sniffles) am I gonna be just sitting back waiting for her again?
Therapist: I think that just coming here, talking about this, showing you care, facing
these feelings – all of that already is an act of love and commitment. I don’t know
how far you will be able to go – how comfortable with Adela’s bisexuality and
accepting you will become or whether the two of you will ever be able to become as
close as you once were. I do know that, through our work together, I hope you both
will remember that you need each other. Your criticism and her suicidal despair have
to stop. Even if all that happens in the course of our work is that you protect her
more, that is meaningful.
Mother: We just . . . never . . . we don’t talk about it.
Therapist: I understand that and that will be part of our work. It is okay that you
feel discomfort, sadness, loss, etc. And I think that that’s a really honest thing. I
think that it is okay to say to her . . .‘Here is where I am at.’ I do not want you to lie
to her and say you are okay with this when you are not. You just need to tell her
that you are willing to work on it. That is the starting point. All you can promise is
that you will try and you will not humiliate or criticise her . . . What do you think
about that?
Mother: I am willing to try . . . I’ll give it a shot if it helps. It’s tough.
Therapist: Yeah, it is tough.
Mother: It’s painful.
Therapist: Yeah, and it’s hard to be honest about it ‘cause I know that you love your
daughter so much. But I also know that you came into this world with your own
values, and your hopes and your dreams for her. And it’s okay to be sad that those
things might not necessarily happen, or they might not look the way you want them
to. And it takes time to adjust to that . . .
In this segment, the therapist validated Edith’s feelings of loss, disgust, pain, etc.,
and gave her permission to have the time to change. This often frees up parents to
say things out loud that they have not permitted themselves to say privately. The
therapist also helped Edith make the distinction between accepting and liking. Finally,
the therapist made the distinction between not liking her daughter’s sexual orientation
and acting hurtfully toward her daughter because of her sexual orientation.
As Edith came into contact with her loss, pain, etc., she began to mourn. Through
this mourning process, the therapist empathised with Edith, but also challenged some
of her misconceptions (e.g., ‘My daughter will never have a wedding’). In the follow-
ing session, the therapist successfully prepared Edith to listen to her daughter.
Task III was not a linear process for Edith. The therapist and Edith worked
through deep reaching fears, disappointments, and losses she was holding onto. Each
of these had to be explored, validated, and processed. In addition, Edith’s many mis-
conceptions had to be examined and re-evaluated in order for her to move forward.
Most importantly, Edith was released from the expectation that she needed to imme-
diately and completely feel comfortable with her daughter’s sexuality in order to be
empathic to her child’s needs and pain.

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Task IV – Repairing Attachment

The goal of the attachment task (Task IV) is to help the family have a corrective
attachment experience: the adolescent brings up difficult emotional problems related
to the parents and parents provide comfort, protection, and sensitivity. In the follow-
ing segment, Adela discussed her past fear of coming out to her mother.
Adolescent: Um, I’m not sure where to start.
Therapist: I think there’s a couple of entry points . . . maybe we should start at the
beginning . . . when your mum found out you were bisexual.
Adolescent: That was really hard for me. When you first found out, . . . it hurt a lot
because you wouldn’t even look at me or talk to me. This is what I had always feared
you would do, I mean, like, we’ve never really talked about it. It’s almost like it
didn’t even happen. Which hurt too because it’s like, it’s almost like you’re ignoring
that part of me.
Mother: First I want to say that I’m here for you and I’m sorry I hurt you. It was
hurtful to me and I didn’t know how to deal with it. I grew up with not knowing
how to confront situations and not knowing how to deal with them immediately.
That’s why I’ve always told you, give me time, give me a day or two, don’t I always
say that? Let me know ahead of time.
Therapist: I think that what you’re saying is great, but I’m wondering maybe before
we go into your side of things, because I know that you have a lot to say to Adela.
But maybe, Edith, you can find out a little bit more, of what it was like for her to
have kept it from you.
The therapist stopped Edith here and acknowledged her apology. Edith was trying
to engage positively, but she had not yet given her daughter the opportunity to fully
express her thoughts, feelings, and memories. The goal was to help Adela speak about
her experiences in as complete a manner as possible, while Edith focused on under-
standing her daughter. In this way, while the family is working through relational dis-
appointments, Adela is also working through her internal construction of what
happened and how she felt. Given the freedom to explore this story and avoiding
emotions helps adolescents develop a more coherent and emotionally integrated
understanding of themselves and their relationships.
Adolescent: I mean, I didn’t want to. like. hide it, but I was scared about how you
were gonna react. I mean I wanted to tell you because I felt like, you’re my mum, so
stuff like that I should be able to tell you. I didn’t feel like I could. And it’s like, I
was just scared . . . about how you were gonna react because I mean . . . I knew you
didn’t really, like, approve of that kind of thing but, so um . . .
Mother: I’m trying, because I love you and you mean the world to me . . . Who I
am today is a total different person. I’m still me, but my maturity level, um, I handle
things completely different. Yes, I used to blow up before and that’s exactly what
happened. I found out in a not good way, you didn’t come to me and tell me and I
found out, and that was my reaction. And I know I haven’t had good reactions since
then, but I’m going to do all that I can to support you and to learn more about
it . . . I don’t know what else to do but support you.

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

Adolescent: That’s all I want. That’s all you can do anyways, that’s all I wanted.
Therapist: You know Adela, I can see that mum’s response is really meaningful to
you and I think mum is being really brave and taking responsibility and apologising.
I am also impressed by how understanding you are. I was wondering, though, if there
was something mum could do in the meantime as you worked through all of this
together to help you feel better. You know, you talked about the negative comments.
Tell your mum what it has been like to hear her call you names.
Adolescent: It’s been horrible mum. It’s made me feel all alone and rejected by you.
Mother: I understand how hurtful that is been. I’m sorry. It is hard for me. I still
can’t watch you and another girl together without cringing. Right now, I am not
going to lie. I wish you were just like any other girl, but I understand how my words
are hurtful. I will stop that. And if I slip, you can tell me. I want you to tell me so
that I don’t do that anymore.
Over the next few weeks, Adela had a growing sense that mum was genuine in
her intentions and had started to change. In fact, at one point, Edith asked Adela if
she could wear Adela’s pride bracelet between sessions. During subsequent conjoint
attachment sessions, the conversations seemed to flow more easily and, as trust and
intimacy increased, new challenges were explored. Adela talked with her mother about
witnessing Edith’s domestic violence and her resentment about the frequent moving.
Adela also talked more directly about how her mother shamed and humiliated her.
Edith remained non-defensive and empathic, inviting Adela to share her feelings, ask-
ing questions, and trying to understand. These conversations clearly brought relief
and a sense of closeness to them both. Although no conversation could actually
change the events of the past, Adela no longer experienced feeling rejected by her
mother. Both Adela and Edith felt they could move forward with more connection
and better communication.

Task V – Promoting Autonomy

The family only needed three conjoint attachment sessions before moving on to promot-
ing autonomy sessions (Task V). Task V shifts away from an explicit focus on ruptures
in the relationships and more onto challenges in the adolescent’s life, with the parent
serving as a secure base of support. Topics focused on discussing plans for the future
(i.e., school, relationships, sex, and involvement in the LGBTQIA community) and
Adela’s father’s disengagement. Throughout these conversations, Edith and Adela used
their new skills and new-found trust to speak about these issues in a more open and
mutually validating manner. Instead of becoming dismissive and defensive, Edith would
listen openly to her daughter’s experiences and perspectives. As a result, Adela stayed
engaged in the conversation and was honest and emotionally regulated. The more Adela
was honest with her mum, the more Edith could trust her. Additionally, the more Edith
and Adela discussed Adela’s sexuality honestly, the more accepting Edith became of Ade-
la’s bisexual identity. The following segment is an example of how Adela and Edith
began to handle the difficult issues surrounding Adela’s sexuality.
Mother: She didn’t know but I didn’t sleep last night because I’m worried about her
making the right decisions when it comes to Eddie [the bisexual boyfriend] because

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you’re not opening up to me so I don’t know, I’m scared that you’re not going to
come to me when you get to that point [having intercourse] and you feel that you
and Eddie want to take the next step.
Adolescent: I guess I was thinking about the same thing when I was going to sleep.
If it came to that point, would I be able to tell you about it and like . . . how I
would want to . . . and I’d be scared to and I would just, like I don’t know because
it’s so weird . . . I can’t. I wouldn’t be able to anticipate what you would say and I
was thinking about it right before I was sleeping.
Therapist: What were you worried she would say?
Adolescent: I don’t know – that’s the problem. I didn’t know what to expect. That’s
the scary part.
Therapist: So why don’t you ask her now?
Adolescent: Like if I did decide to tell you I’m going to have sex with him, I have
no idea what you would say, and that is scarier than actually saying it.
Mother: What I would say is that number one it’s your decision and number two,
are you ready? And if you are, you need to get protection. I need to get you
protection.
Adolescent: So you wouldn’t tell me not to do it?
Mother: No, I’m not going to say that because I know how I felt about being with
someone when I was your age, I wanted to be with someone, and I know that I had
those strong feelings. It was just unfortunate that I had to go up there and learn on
my own. I couldn’t talk to my mum about this stuff.
Adolescent: I thought you were gonna like get mad, I don’t know why but that’s
kinda what I was expecting.
Mother: I also have another question, not another question but a concern because I
didn’t have the choice to make the decision ‘was I ready or not.’ Do you want to do
this now in your life or do you want to wait and see? Like maybe, you know, if
you’re gonna find somebody that you’re really in love with? Or are you really in love
with Eddie? Do you think that the relationship is gonna last for a while? Do you
look to the future for you and Eddie? Do you want it to be just something casual?
There’s a lot of questions, there’s a lot of questions that you have to think about
before you do it.
Adolescent: Yeah I know, I actually think about that a lot, whether me and him are
gonna last that long and I don’t know. For no particular reason I feel like we are.
Edith and Adela continued to discuss relationships and qualities to look for in a
partner. Edith was less preoccupied with her daughter’s sexual identity, which opened
space for her to have conversations about sex, love, commitment, and contraception.
Edith was impressed with how thoughtful her daughter had been, making her feel
comfortable granting Adela more psychological and behavioural autonomy. Given
mum’s history of domestic violence, themes of protection and safety came up repeat-
edly throughout therapy. However, as a result of the new trust between Edith and

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 Suzanne A. Levy, Jody Russon, and Gary M. Diamond

Adela, Adela no longer experienced her mother’s questions as a lack of trust, but
rather as an act of love.
Through the use of ABFT for LGB suicidal youth, Edith and Adela’s relationship
was transformed by the end of therapy. While Edith was still working on her process
of acceptance regarding Adela’s sexuality, she was no longer insulting or criticising her
daughter. Additionally, Edith was taking measures to understand bisexuality and cope
with her own homophobia and fears. Since Adela no longer felt rejected and criticised
by her mother, she was able to use her mother as a secure base so that she could fur-
ther explore her autonomy.

Case Review
This case represents a successful therapeutic course of ABFT, where issues of sexual
identity were at the forefront of the relational ruptures. By the end of the therapy,
the adolescent’s suicidal ideation decreased from 32 (clinical level) to 4 (below norma-
tive level) on the Suicide Ideation Questionnaire – Jr. While Adela’s depressive symp-
toms remained elevated, they decreased from a 34 to a 25 on the Beck Depression
Inventory. Additionally, her attachment-related avoidance and anxiety toward her
mother had reduced from an ECR Avoidance score of 6.83 at intake, to 2.50 at post-
treatment; and from an ECR Anxiety score of 4.25 at intake, to 1.25 at post-treat-
ment. Parent–child communication was also improved.
This case reflects some of the essential components of ABFT for depressed and
suicidal LGB adolescents. The particular themes and obstacles toward acceptance
and reconnection, however, will vary from case to case. For some parents, the ther-
apy may revolve around their shame and fear of what others in their family and
community might say. For other parents, substantial time and conversation might
be devoted to helping parents ask about and hear their child’s experience of coming
out to themselves, in order to help them come to terms with their child’s LGB
identity. In all cases, however, the thrust of the work involves identifying how dis-
engagement, criticism, shame, fear, and anger, associated with parental non-accep-
tance, have compromised the parent–child relationship and the child’s well-being.
Furthermore, working to establish safety, mutual respect, and intimacy restores secu-
rity in the relationship.

Acknowledgment
This paper was supported by a grant from the American Foundation for Suicide
Prevention.

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