Depression and attachment in families: a child-focused perspective
Given the social nature and developmental implications of attachment and depression, in this review we will examine the role of attachment and the effects of a depressed family member at each stage of a child’s development. We discuss treatment strategies for families in which either a parent or a child is depressed. We propose a model that is based on the developmental phase of the children in the family, and that aims to strengthen attachment bonds among family members and alleviate depressive symptoms.
Fam Proc 41:494-518, 2002
EMOTIONAL bonds among family members are key in psychological development and functioning. Through attachment bonds, people develop internal working models of self, relationships, and ways of interacting based on early caregiving experiences (Bowlby, 1969, 1973). To construct an optimally adaptive working model, the child must bond with a caregiver who offers consistent nurturance, soothes negative affect states, and tolerates the child’s full display of emotions toward self and others. A child is at risk for forming an internal working model with unfavorable implications for long-term adjustment if the caregiver fails to respond in a consistent, empathic, and supportive manner to the child’s displays of affective distress. These latter caregiver tendencies are associated with the development of an insecure attachment relationship, such that the child develops a working model that significant others cannot be relied upon for assistance in regulating negative affects. As a result, the child fails to develop the capacity to regulate negative affect states and is at increased risk for depression (Cole & Kaslow, 1988).
The interaction between attachment and depression is complex. On the one hand, insecure attachment relationships in the formative years may predispose an individual to depression later in life. On the other hand, depression may lead to difficulties in developing and/or sustaining positive and secure attachment relationships. Furthermore, a child’s depression may present unique challenges to other family members in terms of bonding with the child. To date, there is a lack of empirical evidence regarding the directionality of the interaction between depression and attachment difficulties. It is likely that the causal link between depression and attachment difficulties varies for different children and families, and that in many cases the development and maintenance of depression and attachment problems are inextricably interwoven. Further, there are multiple and often interacting causal pathways for depression in young people that include genetic, biological, psychological, and social factors.
Regardless of the causal nature of the attachment-depression link, the strong association between the two suggests that attachment theory is relevant to effective treatment endeavors with families with a depressed member (Sexson, Glanville, & Kaslow, 2001). In this article, we examine how depression affects parenting and the mechanisms associated with the formation of attachment bonds, and then focus on children who are depressed, and on the role of attachment. We will offer developmentally informed models for interventions with depressed families, which focus on reconstructing secure attachment bonds. Our focus on the attachment-depression link and on the use of attachment-based family interventions for depressed youth is not meant to imply that families are to blame for their children’s depression nor that attachment-based family interventions are the sole treatment of choice, nor that all families of depressed youth will benefit from such interventions.
Before we discuss the depression-attachment link, a brief review of the various attachment styles is in order. In terms of early child attachment styles, there are four main typologies: anxious-avoidant (A), securely attached (B), anxious-resistant (C), and disorganized/disoriented (D) (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990; Solomon & George, 1999). Infant attachment styles are stable over time (Lamb, Thompson, Gardner, Charnov, & Estes, 1985), consistent across generations (Benoit & Parker, 1994), and best predicted by caregiver attachment styles (van IJzendoorn, 1995). In recent years, attention has been paid to the attachment styles of adults (Bartholomew & Horowitz, 1991; Murphy & Bates, 1997). Main and colleagues developed a typology in which adults are categorized by attachment styles associated with childhood styles: dismissive, secure-autonomous, preoccupied, and unresolved/disorganized (George, Kaplan, & Main, 1996).
Depression in Parents
Children of depressed parents are at risk for psychopathology (Goodman & Gotlib, 2001) because of one or more of the following interacting risk factors: heritability of depression, dysfunctional neuroregulatory mechanisms, exposure to negative maternal cognitions, and the stressful context of the children’s lives (Goodman & Gotlib, 1999). As a result, the offspring may experience increased psychobiological, cognitive, affective, behavioral, and interpersonal vulnerability, which is moderated by the father’s relationship with the child, course and timing of the mother’s depression, and child characteristics. The model has implications for an attachment perspective. A positive attachment to a nondepressed father can serve as a protective factor (Conrad & Hammen, 1989). Conversely, a depressed mother combined with a father with emotional difficulties is associated with insecure attachments (Eiden & Leonard, 1996). In addition, exposure to the mother’s maladaptive attachment style may increase the child’s likelihood of developing maladaptive interpersonal behaviors and subsequent psychopathology.
The attachment style of the parent who suffers from depression may play an important role in parenting behavior. Depression affects the mother’s availability and sensitivity to the child and thus could affect the child’s development of a secure attachment representation. Insecure parents are less warm and provide less structure for interactions than secure parents (Cohn, Cowan, Cowan, & Pearson, 1993). More hopeful is the finding that while insecure early attachment style may lead to depression, parenting style may be less affected if the individual experiences secure working models in adulthood (Pearson, Cohn, Cowan, & Cowan, 1994). This suggests that subsequent relationships may compensate for possible emotional deficits in early childhood, at least in terms of parenting behavior.
We now focus on maternal depression and childrearing at each developmental stage, followed by a discussion of paternal depression and childrearing.
Infancy: After delivery, many women suffer from postpartum depression (PPD), which affects their energy level, availability, and interaction style (Campbell, Cohn, Flanagan, et al., 1992). Compared to nondepressed mothers, mothers with PPD are more likely to have flat affect, be less responsive to infant cues, be less affectionate, be less affirming and more negating of infant experience, and be more intrusive or hostile (C. T. Beck, 1995; Murray, Fiori-Cowley, Hooper, & Cooper, 1997). Their difficulty in developing synchronous interactions with their infants places their infants at risk for insecure attachments (Field, Healy, Goldstein, & Guthertz, 1990). The prognosis is best when there is partner support (Campbell et al., 1992) and when the mother’s depression lasts for less than 6 months (Campbell, Cohn, & Meyers, 1995) or is relatively mild (DeMulder & Radke-Yarrow, 1991; Radke-Yarrow, McCann, DeMulder, et al., 1995).
The effects of PPD on infants are considerable. Compared to infants of nondepressed mothers, infants of depressed mothers display more negative affect; are less consolable, attentive, and cognitively competent; and have lowered mental and motor development (C. T. Beck, 1995; Lyons-Ruth, Zoll, Connell, & Grunebaum, 1988; Murray et al., 1997; Whiffen & Gotlib, 1989). Lifetime maternal depression is associated with insecure infant attachment, particularly when comorbid with another form of psychopathology (Carter, Garrity-Rokous, Chazan-Cohen, et al., 2001).
Preschool: Maternal depression also affects parenting practices and attachment formation during the preschool years. Two- and three-year-old children of depressed mothers demonstrate more insecure attachments than toddlers of nondepressed mothers (Lieberman, 1992; Radke-Yarrow, Cummings, Kuczynski, & Chapman, 1985), perhaps because of depressed women’s difficulty coordinating interactions with their preschoolers, or repairing interrupted interactions (Jameson, Gelfand, Kulcsar, & Teti, 1997). Also, children without unitary, coherent attachment strategies have more chronically impaired depressed mothers than preschoolers with more coherent and organized attachment strategies (Teti, Gelfand, Messinger, & Isabella, 1995). Two groups of preschoolers vulnerable to depression at later periods are those who develop insecure attachments in the context of severe maternal depression (Radke-Yarrow et al., 1995) and those of teenage mothers (Hubbs-Tait, Hughes, Culp, et al., 1996).
Not all infants and preschoolers of depressed mothers manifest attachment difficulties. Some securely attached infants and toddlers whose mothers are depressed engage in caregiving behaviors toward their depressed mothers (Radke-Yarrow et al., 1995). For some children, such parentification behaviors are associated with negative developmental outcomes (Radke-Yarrow et al., 1995). However, for other children, such behaviors may facilitate the children’s bond with their mother, which may in turn decrease their risk for later emotional problems (Radke-Yarrow, Zahn-Waxler, Richardson, et al., 1994).
Middle childhood: When a child’s mother suffers from depression during middle childhood, that child is at risk for developing a mood disorder or other psychosocial difficulties (Radke-Yarrow, Martinez, Mayfield, & Ronsaville, 1998). Insecure mother-child relatedness is associated with hopelessness in children at this stage (Wood, Klebba, & Miller, 2000). However, mother-child interaction quality partially mediates the link between maternal depression and child problems (Harnish, Dodge, & Valente, 1995). The limited literature on the attachment patterns of elementary school children of depressed parents suggests that these children may have problems with interpersonal relationships (C. A. Anderson & Hammen, 1993).
Adolescence: The limited available data reveals that adolescents of depressed ‘ mothers are at increased risk for developing depression, suicidal behavior, and other forms of psychopathology (Fergusson, Horwood, & Lynskey, 1995; Klimes-Dougan, Free, Ronsaville, et al., 1999; Radke-Yarrow et al., 1998). High levels of family-wide stress combined with mothers’ depression-related dysfunction are related to increased levels of depression (Radke-Yarrow et al., 1998).
Depressed mothers of adolescents demonstrate high levels of negativity, anger, and criticism toward their children (Radke-Yarrow et al., 1998; Tarullo, DeMulder, Martinez, & Radke-Yarrow, 1994). They often are emotionally unavailable and/or responsible but insensitive to their adolescents’ needs. In many families with depressed mothers and adolescent children, fathers contribute to the hostile environment with their own violent behavior, and add to the parental unavailability by not being consistently responsible in their parenting (Radke-Yarrow et al., 1998). Most depressed parents of adolescents struggle to be good parents, dealing with their own depression and the challenges associated with parenting an adolescent, particularly one with emotional difficulties. Thus, not surprisingly, one-third of depressed mothers of adolescents offer some positive nurturing to their children, and many fathers serve as stabilizing and nurturing figures (Radke-Yarrow et al., 1998).
Paternal depression: Little is known about the effects of paternal depression on children or on attachment relationships. Children of depressed fathers are at risk for emotional and behavioral problems, and manifest such difficulties at a level comparable to those observed in children of depressed mothers (Phares & Compas, 1992). Children are particularly vulnerable to depression if both their fathers and their mothers are depressed (Foley, Pickles, Simonoff, et al., 2001; Merikangas, Prusoff, & Weissman, 1988). There is some evidence that paternal depression is associated with internalizing symptoms in sons, whereas maternal depression is associated with internalizing symptoms in daughters (Thomas & Forehand, 1991).
Postpartum paternal depression is associated with attachment problems in infancy (Ferketich & Mercer, 1995), and children’s internalizing and externalizing symptoms in preschool (Carro, Grant, Gotlib, & Compas, 1993). The interaction of depressive symptoms of fathers and mothers predicts subsequent internalizing problems in the child (Carro et al., 1993). Mothers with depressed partners alter their parenting style, and increase their nurturing behavior toward their infants (Zaslow, Pedersen, Cain, et al., 1985).
Jacob and colleagues examined childhood adjustment and family communication patterns of elementary school children with a depressed mother, a depressed father, or no depressed parents. Results showed that paternal and maternal depression were similarly associated with child adjustment problems and impaired parent-child communication (Jacob & Johnson, 1997). Findings also indicated that father-child interactions were more influential than mother-child interactions in predicting child outcome. This may be attributable in part to that fact that positivity suppression characterizes the interactions of families of elementary school children with a depressed father, but not with the depressed mother, or with no depressed parent (Jacob & Johnson, 2001). Consistent with these findings, evidence suggests that paternal depression may be a stronger predictor than maternal depression of adolescent depression (Forehand & Smith, 1986).
Depression in Children
This section discusses the link between depression and attachment in children during infancy and early childhood, middle childhood, and adolescence.
Infancy and early childhood: Frequently, in the context of a depressed or absent mother, infants, toddlers and preschoolers develop symptoms suggestive of depression (M. Cummings & Cicchetti, 1990). Historically, Spitz (1946) and Bowlby (1969) described a depression-like syndrome in infants separated from their mothers. These infants appeared depressed, cried frequently, were unresponsive to their environment, and showed abnormalities in sleep and feeding behaviors. Such infant behaviors are indicators of attachment and regulatory disorders (Zeanah, 2000).
Depression among toddlers is sometimes characterized by withdrawal, passivity, and behavioral inhibition during play with a familiar peer (Rubin, Booth, Zahn-Waxler, et al., 1991). Similarly, dysphoria in dyads in which one friend has an insecure attachment is more common than when both peers are securely attached (Park & Waters, 1989). Insecure attachment among preschoolers predicts internalizing problems (Anan & Barnett, 1999), a link mediated by levels of perceived social support.
Middle childhood: During the transition into middle childhood, depression is associated with deficits in affective, cognitive, interpersonal, and adaptive behavior functioning (N. Kaslow, Croft, & Hatcher, 1999) and often co-occurs with other internalizing and externalizing behavior problems (Birmaher, Ryan, Williamson, et al., 1996). During this developmental phase, negative peer interactions place a child at risk for depression (Cicchetti & Toth, 1998). Children with insecure attachments experience more internalizing disorders (Easterbrooks, Davidson, & Chazan, 1993) and negative peer interactions (Urban, Carlson, Egeland, & Sroufe, 1991) than children with secure attachments.
Adolescence: Depressed adolescents often manifest impairments in school performance, social relationships, physical health and global functioning; substance abuse; and early pregnancy (Birmaher et al., 1996). Depressed adolescents, particularly those with severe depressions, report less secure parent and peer attachment than nondepressed psychiatric controls or nonpsychiatric controls (Armsden, McCauley, Greenberg, et al., 1990). Adolescents with resolved depression have attachment securities comparable to nonpsychiatric controls (Armsden et al., 1990), suggesting that attachment quality may depend on mood-state, at least during adolescence.
Adolescents who report greater attachment to parents report less depression and more positive perceptions of family expressiveness and cohesion than adolescents with less secure attachments (Papini, Roggman, & Anderson, 1991). Conversely, adolescents with an insecure attachment style exhibit many of the indicators of depression, including psychological distress, low self-esteem, and difficulty with emotional regulation (Armsden & Greenberg, 1987; Cooper, Shaver, & Collins, 1998; C. L. Hammen, Burge, Daley, et al., 1995). In addition, adolescents with insecure, anxious, and ambivalent attachments report higher levels of depressive symptoms than peers with secure attachments (Allen, Moore, Kuperminc, & Bell, 1998; Kobak, Sudler, & Gamble, 1991; Raja, McGee, & Stanton, 1992). Preoccupied attachment appears to be linked to depression (Allen et al., 1998; Kobak et al., 1991; Rosenstein & Horowitz, 1996), and comorbid depressive and eating disorder symptoms (Cole-Detke & Kobak, 1996). Further, attachment strategies or cognitions account for significant variance in concurrent and prior levels of depressive symptoms (Burge, Hammen, Davila, et al., 1997; Kobak et al., 1991). The association between insecure attachment strategies and depressive symptoms is stronger in females; in males, preoccupied attachment strategies are more related to depressive symptoms. Insecure attachments in female adolescents also are associated with the use of ineffective strategies in dealing with interpersonal conflicts (Torquati & Vazsonya, 1999).
Attachment-based therapy for families with a depressed parent(s) and/or child(ren) should be guided by a number of principles. First, it is helpful for the therapist to espouse an interactional view of the maintenance of depressive symptoms and associated interpersonal behaviors (Joiner & Coyne, 1999). This perspective suggests that all family members be involved in various stages of the intervention and that people who support the family and depressed family members be included. Second, it is recommended that interventions be tailored to the developmental stage of the children and flexible enough to accommodate the capacities of the various participants. Some modalities, such as play, are particularly amenable to families with children representing a variety of developmental stages (Gil, 1994). Third, given cross-cultural differences in attachment patterns and parenting styles, it is optimal for interventions to be conducted in a culturally competent and specific manner (Crittenden & Claussen, 2000) and take into account the fact that attachment relationships are both universal and culturally shaped (Harwood, Miller, & Irizarry, 1995). Fourth, it is important that the therapist actively and warmly engage and join with each person present; offer empathy and support; and create a safe and secure holding environment where affective distress is modulated, conflicts are resolved, and individuals feel protected and not criticized (Byng-Hall, 1995; Diamond & Siqueland, 1995). It behooves the therapist to act as the secure base from which members of the family can explore both greater connection with one another and healthier levels of separation and individuation (Byng-Hall, 1995). The presence of a positive working alliance enables all family members to develop more positive working models of self and others and interact more effectively (Erickson, Korfmacher, & Egeland, 1992). Fifth, an attachment perspective underscores the importance of forging secure attachment relationships among family members, either by rekindling existing attachments (reattachment) or developing secure relationships for the first time (Diamond & Siqueland, 1995). This may entail sessions focused on parent-child dyads, sib-ships, couples, adult caregivers (e.g., mother-grandmother), and so on.
Finally, attachment-based family interventions for depression often need to occur concurrently or sequentially with other intervention modalities since the link between parental and child depression is accounted for by a number of factors in addition to the parent-child attachment relationship: for example, the nature of the parents’ depressive symptoms, the parents’ attachment histories, the parenting practices of child management, marital conflict and distress, and the child’s own characteristics and symptoms (Cowan, Cohn, Cowan, & Pearson, 1996; E. M. Cummings & Davies, 1994; E. M. Cummings, DeArth-Pendley, Schudlich, & Smith, 2001; M. Cummings & Cicchetti, 1990; C. Hammen, 1992). Thus, depressed parents may benefit from interpersonal psychotherapy, cognitive behavioral treatment, and/or pharmacological interventions (A. T. Beck, Rush, Shaw, & Emery, 1979; Klerman, Weissman, Rounsaville, & Chevron, 1984; Schatzberg & Nemeroff, 1998). If the adults have difficulties with child management, they may benefit from learning such skills in a fashion tailored to addressing the unique issues associated with parenting a depressed child (Stark, Napolitano, Swearer, et al., 1996). When relationship conflict or discord is present, couples therapy for depressed adults is recommended (Beach, 2001; Beach, Sandeen, & O’Leary, 1990; Cordova & Gee, 2001; Jacobson, Dobson, Fruzzetti, et al., 1991; Jacobson, Fruzzetti, Dobson, et al., 1993). These interventions are most in keeping with the family work if they are guided by attachment theory (P. Anderson, Beach, & N. J. Kaslow, 1999; Whiffen & Johnson, 1998). In sum, the child’s affective, cognitive, behavioral, and interpersonal characteristics, and psychological symptoms may be addressed by one or more of the following empirically supported treatments, cognitive-behavioral therapy, interpersonal therapy, or pharmacology (N. J. Kaslow, McClure, & Connell, 2002; E. B. McClure, A. M. Connell, M. Zucker, et al., in press; Michael & Crowley, 2002).
This section provides information about family interventions–for children at different developmental stages–that incorporate family systems theory and attachment theory, and build upon the prior literature review. The goals of these interventions are to reduce depression in all depressed members and enhance attachment bonds for all participants. We refer to families as “depressed families” to indicate the presence of depression in one or more member. The term “depressed family” indicates that there is at least one child in the target age group and at least one family member (child or caregiver) who manifests symptoms consistent with a relational diagnosis of depression (N. J. Kaslow, Deering, & Ash, 1996). When families include children from more than one age group, it is suggested that the family intervention be adapted so as to be developmentally appropriate for each relevant age level by combining the techniques described below for each age group.
Infancy: When working with families with infants who appear depressed and/or with a mother experiencing PPD, techniques from infant-parent psychotherapy and relational treatment approaches for PPD may be helpful. Infant-parent psychotherapies evolved from object relations and attachment theories, and bring together techniques from psychodynamic psychotherapy, developmental guidance, and the management of family’s basic needs (Fraiberg, 1980; Fraiberg, Adelson, & Shapiro, 1975; Lieberman & Pawl, 1993; Stern, 1995). Historically, these approaches included the primary caregiver and the infant. However, we recommend that the strategies of parent-infant psychotherapies be incorporated in an intervention that includes all family members. It is helpful to use a psychoeducational approach in which members are educated about the signs, symptoms, and sequelae of depression (G. N. Clark & Seifer, 1983; R. Clark, Paulson, & Seidl, 1998). This enables them to be more accepting of their loved one’s depression.
It is likely to be beneficial to the family if the therapist offers education about infant development and healthcare needs, models appropriate interaction strategies and activities, teaches parenting skills, and provides other sources of public assistance (Gelfand, Teti, Seiner, & Jameson, 1996). These educational interventions may be associated with increased acceptance of the infant, greater self-efficacy in all members, improved success in engaging the baby in positive interactions, and more positive infant development (Gelfand et al., 1996). Therapists also may find it to be advantageous if they help caregivers understand how their own histories and internal working models affect their parenting; resolve problematic attachment histories; increase cognitive and interpersonal coping strategies; and address depressive schema (R. Clark et al., 1998; Erickson et al., 1992; Seligman, 1994).
At the same time, it is recommended that the therapist conduct interventions that directly target enhancing emotional and behavioral synchrony and empathic attunement within the caregiver-infant dyads, as well as between older siblings and the infant. This can be accomplished in a number of ways. The family therapist can provide practical, nondidactic developmental guidance regarding various aspects of the child’s physical, cognitive, social, and emotional development; and offers direct support (referrals, practical assistance) and advocacy. The therapist may help the family track their own responses, as well as the responses of the infant, so that older family members begin to link their subjective responses to the infant with the infant’s immediate concrete experience, and makes interpretations accordingly. One particularly useful intervention technique is “previewing” (P. Trad, 1992; P. V. Trad, 1993). The aspect of previewing most pertinent to working with “depressed families” with infants relates to enhancing family members’ sensitivity to subtle infant cues, particularly those related to affective distress and problems with affective regulation.
Another useful and related strategy is interaction coaching, which has demonstrated efficacy in improving the relationship between depressed mothers and their young children (Malphurs, Larrain, Fields, et al., 1996). Interaction coaching aims to improve the family’s attunement to the infant and foster family members’ ability to respond appropriately to the infant’s cues, which leads to more appropriate and attentive responses from the infant (Field, 1997). Results from a study of interaction coaching with depressed mothers and their 3- and 6-month-olds revealed that mentoring mothers to engage in a positive manner with their babies, and designing the coaching approach to the mother’s particular style of interaction (i.e., intrusive mothers are taught to engage in imitative behaviors whereas withdrawn mothers are encouraged to be more attentive), is associated with infants’ becoming more positively engaged with their social environments (Malphurs et al., 1996).
Additionally, music and massage therapies, as well as touch, have demonstrated efficacy for alleviating mood problems in depressed or anxious parents and reducing arousal in distressed infants. Such interventions facilitate the caregivers’ and infant’s responsiveness to interaction coaching, enhance family interactions, and foster the development of more secure attachments (Field, 1998; Field, Grizzle, Scafidi, & Schanberg, 1996; Pelaez-Nogueras, Field, Hossain, & Pickens, 1996). Other research reveals that when depressed mothers of newborn infants observe the administration of the Neonatal Behavioral Assessment Scale and then administer a similar measure to their infants, they learn more about their infant’s behaviors, strengths, and preferences, and as a result interact more competently with their babies. Their infants become more skilled in social interaction and state organization, and demonstrate greater improvements in their social, motor, and state organization skills (Hart, Field, & Nearing, 1998). This finding indicates that helping mothers to acknowledge their baby’s capabilities and encouraging regular interaction, rather than just attending to the infant’s physical needs may be associated with a reduction of risk factors for maternal depression.
All of these interventions increase family members’ confidence, enhance active engagement and emotional attunement with the infant, and improve the security of the infant’s attachment to all family members (Lieberman, Weston, & Pawl, 1991). Members manifest an increased capacity to provide consistency, nurturance, and developmentally appropriate stimulation to the infant (R. Clark et al., 1998). As a result, there is a greater experience of positive affect, responsiveness, and mutual enjoyment among all members (R. Clark et al., 1998).
In addition to the previously noted attachment-based family interventions for “depressed families” with infants, other approaches may be indicated. For example, Clark and colleagues (G. N. Clark & Seifer, 1983; R. Clark et al., 1998) have developed a group model for the treatment of women with PPD and their infants, which includes mothers’ groups, infants’ groups, and dyadic groups. Home-based interventions may be particularly efficacious in reducing depressive symptoms and daily hassles for mothers, and enhancing maternal and child adjustment (Gelfand et al., 1996), particularly for families that have numerous obstacles to attending sessions at a treatment facility.
Loretha is a 24-year-old single African American female who was first seen
when she was 3 months pregnant with her third child. Her mother was raising
her 8-year-old son, and she was caring for her 5-month-old daughter, Maya.
She asked to be seen by the psychiatric obstetrics service when she became
depressed after learning about her partner’s (Demetrius) affair with
another woman. Given the severity of her depressive symptoms, including
suicidality, she was placed on an antidepressant medication. Since her
depressive symptoms were interfering with her attachment to her infant as
well as her fetus, and because she had never formed a meaningful connection
with her son, Xaviar, an attachment-based family intervention was
undertaken. Initial sessions were held with Loretha and Maya. In addition
to educating Loretha about normal infant development, the therapist coached
her to imitate everything her baby did and to do whatever should could to
keep Maya’s attention. During sessions, she was encouraged to rock her
baby, to talk with and sing to her baby, and to tickle and cuddle with her
child. Since Maya appeared depressed, Loretha needed to be very active in
her efforts to stimulate her. Fortunately, Maya was responsive to her
mother’s increased attention and playfulness, and as a result became more
interactive. As this mother-infant bond improved, sessions were held on
alternative weeks with Loretha, Maya, and her partner, and then with
Loretha, her mother, Xaviar, and Maya. In the sessions that included her
partner, the work focused on repairing their relationship and clarifying
their commitment to one another. It became evident that although they were
uncertain about their future together as a couple, they acknowledged a
willingness to work together to co-parent the infant and the soon-to-be
born child. Demetrius became more aware of Loretha’s depression and with
some encouragement was able to engage more often in both nurturing and
playing with Maya. In addition, the couple was instructed to sing to the
fetus nightly and to tell the fetus stories each day. In addition, it was
recommended to them that they focus on choosing a name for the child once
they learned it would be a girl, and they chose to call her Love. The
sessions with Loretha, her mother, Xaviar, and Maya will be discussed in
the section on middle childhood.
Toddlerhood: Family interventions for “depressed families” with a toddler are similar in many ways to those described above with infants. However, these interventions should also build upon toddler-parent psychotherapy (TPP), a family-based intervention that uses attachment theory. TPP aims to improve family interactions. All family members are assisted in understanding the toddler’s behavior and affective responses. Attention is also given to emotional reciprocity, particularly of positive affects, between the parent-toddler dyads and the toddler and his/ her siblings. Caregivers are assisted in establishing age-appropriate developmental expectations for the toddler. Finally, the therapist makes linkages between current family interactions and unresolved conflicts arising from the parents’ own childhood experiences (Cicchetti, Rogosch, & Toth, 2000).
TPP (Cicchetti, Toth, & Rogosch, 1999) fosters the toddler’s confidence in leaving attachment figures in order to safely explore the surrounding environment, which results in an increased sense of self-efficacy and reduced vulnerability to depression. In addition, interventions with families with a toddler enable depressed parents to experience themselves as competent caregivers by increasing their ability to respond sensitively and appropriately to their toddlers’ needs. Specifically, responsiveness may be increased through teaching caregivers to attend to, maintain, and repair caregiver-child interactions to more closely approximate normal levels of interactive coordination (Jameson et al., 1997). Interventions that emphasize enhancing caregiver responsiveness increase the security of attachment between toddlers and family members and promote developmental progression through the toddler period. Enhancement of both attachment relationships and cognitive development in the toddler has been demonstrated, even when the parent remains depressed (Cicchetti et al., 2000; Lieberman & Zeanah, 1995).
Results from a study comparing TPP to a no-treatment control, fewer toddlers with depressed mothers in the TPP condition were categorized as insecurely attached as compared to toddlers in the control group (Lieberman, 1992). In addition, at the completion of the intervention, there was not a significant difference in the rates of insecure attachment between the TPP condition and the nondepressed control group, a finding suggestive that attachment security may be improved through intervention (Cicchetti et al., 2000).
Adriana and Miguel, a couple in their mid-twenties who moved to the United
States from Mexico 2 years ago, sought services in an outpatient child
psychiatry clinic because of their concern regarding their 4-year-old
daughter, Julia, who appeared listless and apathetic in her interactions
with her peers and her 2-year-old brother, Juan. A family evaluation
revealed that Adriana had been depressed since moving to the United States,
because she had found the separation from her family of origin to be quite
painful. Adriana noted that she did feel welcomed by Miguel’s family, who
lived in the States. The couple reported that they married after Adriana
became pregnant with their first child, and that although they had tried
their best to make their marriage work, social stressors were negatively
affecting their interactions. Specifically, both worked long hours at low
paying jobs, were not fluent in English, and each had experienced some
medical problems. During the evaluation, it was observed that Juan was
unable to tolerate even brief separations from either parent.
A course of TPP was initiated with all family members over the course of
9 months. The therapist observed the mother interact with each toddler and
the father interact with each toddler, and assisted each parent in
understanding how their own attachment histories influenced their
interactions with their children and with each other. The therapist strove
to form a positive working alliance with each parent, which over time
served as a model of a secure attachment relationship that appeared to have
been disrupted for each parent with regard to his or her respective
families of origins. The therapist encouraged each parent to interact with
each child, often in parallel, with greater attunement and empathy for the
toddler’s affective expressions, interests, and behaviors. As a result of
both in-session guided interactions and at-home play and practice, each
child became more confident in exploring the environment and engaging in
social interactions both within and outside of the family.
Over the course of the family intervention, less emphasis was placed on
dyadic interactions and filial therapy strategies were incorporated
(Ginsberg, 1997; Guerney, 1964; Van Fleet, 1994). Using this approach, the
parents were taught to function as a play therapist with their children.
They learned the symbolism of their children’s play, and received feedback
in the sessions about their attempts to be reflective and empathic in
response to their children’s play. As their capacity to be playful with
their children improved during family sessions, they were instructed to
engage in play sessions at home, take notes on these sessions, and then
return to family meetings for supervision. The parents came to recognize
that empathically reflecting on their children’s feelings as expressed
through their play, communicated to their children a sense of acceptance,
and fostered greater feelings of safety and security. As a result, the
children felt more comfortable in engaging in more genuine self-expression
through their play and words. As Adriana and Miguel gained a greater sense
of pleasure in interacting with Julia and Juan, they also became more
attuned to each other and gained a new appreciation for one another.
Middle childhood: When conceptualizing attachment-based family interventions for depressed elementary and high school children, Hammen’s (C. Hammen, 1992) developmental psychopathology framework for understanding the complex transactions among interpersonal variables, cognitive processes, and life stress is useful. According to Hammen, maladaptive attachment patterns with parents are reinforced by later difficulties in familial and peer interactions. In the context of impaired early social functioning, young people develop maladaptive cognitive styles, including maladaptive models of self and others and ineffective coping skills. These cognitive styles increase the likelihood that stressful life events occur and are associated with difficulty managing stressful events. Thus, attachment-based interventions need to address all components of Hammen’s model.
Guided by the work of Hammen, Kaslow and colleagues (N. J. Kaslow, Deering, & Racusin, 1994; N. J. Kaslow & Racusin, 1988; Schwartz, Kaslow, Racusin, & Carton, 1998) developed interpersonal family therapy (IFT) for depressed children. They also offered a culturally competent adaptation of IFT for African American Youth (Griffith, Zucker, Bliss, et al., 2001; N. J. Kaslow et al., 2002; E. McClure, A. Connell, M. Zucker, et al., in press). When conducting IFT, the therapist attends to joining to enhance the attachment process. This can best be accomplished if the therapist, while conveying hope, empathizes with the vicissitudes of depression in the family and child. The therapist can acquire this balance by regulating the pacing of the interview, and voice quality and tone. The conduct of a thorough assessment of all family members, the provision of feedback regarding the assessment findings, and the collaborative development of a treatment plan further enhances the joining process. An important component of this evaluation is the assessment of each person’s attachment patterns. These data are then used to inform the intervention. Joining sets the stage for repairing disrupted family attachments and developing more positive, secure, and developmentally appropriate relationships.
Early on, IFT therapists provide information regarding the child’s depression and the parents’ depression. They help the family identify precipitants of depressive reactions and discuss adaptive strategies to cope with these stresses (W. Beardslee, Salt, Porterfield, et al., 1993; W. R. Beardslee, Salt, Versage, et al., 1997; W. R. Beardslee, Wright, Rothberg, et al., 1996; W. R. Beardslee, Wright, Salt, et al., 1997; Schwartz, et al., 1998). During this phase of the work, the family therapist communicates an underlying assumption of IFT, namely, that the child’s psychological symptoms and deficits reflect, in part, family systems dysfunction. The therapist helps the family begin to acknowledge the possibility of a correlation between the child’s symptoms and family dysfunction, and assists them in articulating and addressing their feelings associated with family patterns that may exacerbate or maintain the child’s depression. The therapist also works to block scapegoating of the depressed child or other family members for the child’s difficulties.
During IFT, attention is paid to reducing the maladaptive cognitive patterns of each member. Education is provided about the negative cognitive triad, depressogenic attributional patterns, and faulty information processing. Family members are taught to identify depressive cognitions. Depressive cognitive patterns that maintain or exacerbate the “family’s depression” are challenged and changed. Particular attention is paid to negative cognitions regarding attachment relationships. Altering cognitive patterns enables each member to develop more positive working models of self and others.
Another aspect of IFT addresses the affective component of attachment relationships. Family members are helped to label and verbalize both negative and positive affects. The family therapist also educates the family about adaptive cognitive and interpersonal strategies for affect-regulation. As a result, family members are more empathically attuned to one another’s positive and negative affective states, and more able to provide appropriate support in the face of a family member’s distress.
The IFT therapist supports all members in engaging in pleasurable activities with nonfamily members. When limited skills in interpersonal problem solving and/or social skills deficits interfere with any member’s comfort in relationships, such skills are taught during IFT sessions or in group therapy for that individual. As more positive attachment relationships solidify within the family, each person is likely to feel more comfortable developing gratifying extrafamilial relationships. In addition, family members are more likely to actively encourage each other’s activities with age-appropriate peers.
Throughout the duration of IFT, much of the emphasis is on directly enhancing attachment bonds within the family system. Family members are encouraged to engage in pleasurable family activities outside of therapy sessions, some involving all family members and some involving specific subsystems. All persons are expected to focus on one another’s strengths and offer positive feedback. The recipient of such accolades is likely to develop both a more positive working model of the self and other family members.
Finally, problematic attachment patterns characteristic of many depressed families are addressed, such as oscillations between parental overinvolvement with and distancing from the child, parental belittling and controlling of the child, or familial resentment of the depressed child’s needs. The IFT therapist illuminates these patterns, especially as they occur within family sessions, and assists caregivers in maintaining a more evenly present and positive approach to their children. Changes in these patterns on the part of the caregivers results in the children feeling more loveable and supported. Parents need to be encouraged to increase the overall consistency of their nurturance and to reinforce any gains in developmentally appropriate and adaptive behavior. The IFT therapist also challenges the often-distorted inferences that the children draw from their own behavior and performance, and fosters the children’s ability to respond to differences in caregivers’ behavior. In this way, the children reward their parents for their increased support and encouragement. This work attempts to engender more integrated, developmentally appropriate, internal representations of the parents in the children. In doing so, the children’s capacity to sustain attachment to their parents is enhanced.
When working with families with a depressed parent and elementary-school-age children with no psychiatric disturbances, family psychoeducational interventions may prove beneficial (W. R. Beardslee, Salt, et al., 1997; W. R. Beardslee, et al., 1996; W. R. Beardslee, Wright, et al., 1997). These interventions are most likely to be effective if administered by a clinician, rather than in a lecture-group format (W. R. Beardslee et al., 1996). Treatment is most associated with positive benefits when clinicians actively engage the children and make linkages between each family member’s experiences of the depression (W. R. Beardslee, Salt et al., 1997). Furthermore, participation in a clinician-facilitated intervention is associated with the child’s increased understanding of the parent’s disorder and better adaptive functioning (W. R. Beardslee, Wright et al., 1997). This psychoeducational work may lead to increased empathy among all family members regarding both the caregiver’s depression and the effects of the depression on all family members. This enhanced empathy is likely to be associated with greater levels of affective attunement and feelings of closeness.
For families of depressed, middle-school children at high-risk for institutional care (e.g., psychiatric hospitalization, group home) or foster placement, intensive in-home crisis services may be helpful. One such model is the homebuilders model of family preservation (Kinney, Haapala, & Booth, 1991), which includes crisis intervention, effectiveness training, assertion training, fair fight techniques, and behavior modification. Such intensive home-based intervention programs are likely to be necessary in cases in which a child’s depression is in response to multiple family problems, often including abuse, severe parental psychopathology, and/or substance abuse, and limited family support. These family preservation approaches also may be helpful for depressed youth who are younger or older than the middle-school-aged.
To return to the family treatment with Loretha, her mother, Xaviar, and
Maya, we used a developmentally appropriate version of IFT. This approach
was implemented after an evaluation revealed a conflictual relationship
between Loretha and her mother, an insecure attachment bond between Loretha
and Xaviar, and a limited connection between Xaviar and Maya. In addition,
the assessment of all family members’ psychological functioning indicated
that Xaviar also was experiencing depressive symptoms, which appeared
comorbid with his disruptive behavior disorder. Fortunately, by the time
the IFT was initiated, Loretha’s depression had largely remitted, and Maya
no longer appeared listless or withdrawn. For the IFT sessions, a
co-therapy model was employed to insure that all family members would feel
accepted and attended to emotionally. From the outset of the IFT
intervention, the current or historical presence of depressive symptoms in
each family member was noted, and it was suggested that the sadness each
person experienced reflected underlying difficulties in the family
attachment. The therapists reported that the assessment had revealed that
each adult and Xaviar had endorsed having negative feelings about
themselves, felt hopeless and helpless, and tending to blame themselves for
bad events and not take credit for positive outcomes. Age-appropriate
cognitive restructuring techniques were taught to help improve each
person’s self-esteem and enable them to make more adaptive attributions for
their successes and failures. In addition, they were helped to address and
work through their negative feelings about one another, and to develop and
share more positive views of each other.
Since each family member appeared to become overwhelmed with distressing
affects, either sadness or anger, in the face of interpersonal
difficulties, concrete strategies for affect regulation were taught.
Techniques for greater levels of emotion understanding were shared. Various
dyads, triads, and the entire family group were encouraged to engage in
pleasurable activities together. These included playing games, going to the
park, and going to the movies. Each week, at least one family subgroup was
expected to do something special together. Particular attention was paid to
encouraging grandmother to spend time with Maya and Loretha to spend time
either alone with Xaviar or with both children. As Loretha became more
comfortable spending time with Xaviar, her mother became less critical of
her interactions with her son. This process was facilitated by the
therapists helping Loretha and her mother to talk more openly with one
another about their relationship, as well as about each of their parenting
strengths. Slowly, they began to co-parent Xaviar. As Xaviar began to feel
more connected to his mother and sister, his acting-out behavior decreased
markedly, and his self-esteem improved dramatically. His teacher noted at
the parent-teacher conference, attended by both mother and grandmother for
the first time, that not only had Xaviar’s grades improved, but he had also
demonstrated more cooperative interactions with his peers. Xaviar began to
express increased interest in Love’s pending birth. Toward the end of
treatment, which occurred a few months after Love’s birth, a series of
sessions were held with all family members. Roles and responsibilities for
all three caregivers were discussed as related to each of the three
Adolescence: Given adolescents’ needs for greater autonomy and their greater investment in peer than family relationships, less attention has been paid to family interventions for depressed adolescents. However, Diamond and Siqueland (1995) have tailored a family therapy model for depressed adolescents (FTDA) that is guided by an interactional view of depression and reattachment theory.
During the initial phase of FTDA, the family therapist works with parents and adolescents separately, which sets a foundation for the interactional work in the mid- and later stages of the therapy. When meeting with the depressed adolescent, the therapist works to gain an understanding of the adolescent’s social world, perceptions of others, hobbies and activities, and interpersonal competencies and limitations. It behooves the therapist to support the adolescent in identifying and articulating negative experiences and affective distress, prepare the adolescent to negotiate developmentally appropriate privileges and expectations, and examine how to rebuild trusting attachments with other family members. When meeting with the parents during this phase, the FTDA therapist focuses on alliance building, since parents often feel threatened, judged, and emotionally exhausted by the adolescent. In addition to attending to the caregivers’ feelings and perspectives, the therapist lays the foundation for detriangulating the adolescent from parental conflict, bolstering cooperative parenting, and offering strategies to enable the parent(s) to connect with external resources. The parents are helped to find a more adaptive balance between maintaining control and supporting autonomy, supported in setting fair and reasonable limits without being judgmental and rejecting, and encouraged to be loving and available without being overly involved or permissive. During this phase, the adolescent’s depression is reframed as a family, rather than individual, problem. This reframe redistributes responsibility for change onto all family members and defines family relationships as the most powerful contributor to the adolescent’s recovery.
During the second phase of FTDA, the family therapist unites all family members in an effort to break the symptomatic cycle. To accomplish this goal, attachment relationships are repaired, and family social supports identified and strengthened. The therapist helps the family repair the attachment bonds by maintaining the family’s focus on the interpersonal problems that make it difficult for the adolescent to use his or her family as a resource. This entails the therapist’s blocking dialogues that engender negative feelings in various members and helping the family identify the emotions and experiences associated with the mistrust and disengagement. Helping family members nondefensively listen to and acknowledge these experiences diffuses negative affects, and enables them to communicate in a more positive manner. As attachment relationships feel more secure, the family therapist encourages each person who has been depressed to discuss that experience. Family members are likely to share feelings of hopelessness and helplessness, dysphoria, shame and guilt, negative self-perceptions, and suicidal thoughts. The therapist helps others to listen respectfully. The inclusion of extended family members or supportive nonfamily members may provide comfort and resources in and outside of sessions.
During the third and final phase of FTDA, which takes place upon the remission of the adolescent’s depressive episode, the emphasis of treatment shifts toward re-establishing the family as a context of socialization to support the adolescent in rebuilding their family and peer relationships. This entails encouraging the discussion of strategies for the family to manage the conflicts associated with normative adolescent behaviors and interests, supporting the caregivers in respecting the adolescent’s steps toward greater competent independent functioning, and rewarding the caregivers for setting and enforcing age-appropriate goals and expectations. The therapist actively promotes authoritative parenting and encourages age-appropriate autonomy/attachment. Family members continue to be helped to have more satisfying experiences within the family system, which solidifies and reinforces the alterations made within the family environment.
When working with families with a depressed parent and an adolescent with no psychiatric disturbance, clinician-facilitated family-based psychoeducational interventions may prove beneficial (W. R. Beardslee, Salt et al., 1997; W. R. Beardslee et al., 1996; W. R. Beardslee, Wright, et al., 1997). These 6-10 session interventions are designed to prevent the emergence of depression and other disorders in the adolescent, help caregivers recognize distress in the adolescent and respond appropriately, enhance resiliency and reduce risk factors, and increase the families’ understanding of the often traumatic and largely undiscussed experience of parental mood disorders (W. R. Beardslee, Wright et al., 1997). The therapist aims to link the family’s experience of the illness to the information presented in the family meeting. The clinician collaborates with the family in identifying psychosocial stresses, enhancing communication, and delineating and fostering adaptive capacities of family members (W. Beardslee et al., 1993). As noted above, this psychoeducational work is likely to enhance attachment relationships within the family system through the appreciation of each person’s affective experience and strengths and resilience.
Helena is a 16-year-old, Caucasian female from an intact family, with one
younger brother, Bruce age 9. Helena was referred for evaluation by the
school because of her tearful and angry outbursts in class, deteriorating
academic performance, writings in which she expresses a fascination with
death, and a marked narrowing of her social circle and extracurricular
interests. Evaluation sessions held with the entire family, as well as
separately with Helena indicated that she was frightened of her father’s
anger, fearful that her parents’ might divorce, saddened by the death of
her grandmother one year prior, and fearful of the level of autonomy
expected for someone her age. By all reports, Bruce was doing very well
both academically and socially. Her mother, a Montessori schoolteacher,
reportedly enjoyed her job. Her father, an architect, was successful
professionally, but had a history of conflicts with his colleagues. The
family noted that he had been more withdrawn and hostile since the death of
his mother. However, he did not meet criteria for a depressive disorder.
The therapist concurrently held 6 individual sessions with Helena and
six sessions with her parents. In the meetings with Helena, Helena reported
that she felt she did not fit in with her peers, most of who were
experimenting with drugs and sex. She talked about feeling disconnected
from her old friends, and reluctant to form new friendships. She described
situations in which she felt left out or rejected/abandoned by her friends
(e.g., she would set a plan to see a movie with them, and when she called
to confirm, they were not home) and she had become increasingly reluctant
to reach out to them. As a result, she was spending more time alone in her
room or socializing with her parents. The therapist empathized with her
feelings of isolation and her fears of rejection, while simultaneously
supporting her in reaching out to peers.
It became evident that while Helena’s attachment with her mother
appeared secure if not preoccupied, that she was frightened of her father,
and had become less secure in their relationship since the death of her
grandmother. The therapist helped Helena to examine ways in which she could
reattach to her father in a more positive manner, including sharing their
memories of her grandmother and going to tennis matches together. During
sessions with Helena’s parents, family-of-origin dynamics were examined.
Mother revealed that her own mother, who had been dismissive in her
approach to parenting, had died when she was 16, and she began to
understand how this may have challenged her approach to Helena at that
time. The father reluctantly talked about his conflictual relationship with
his own mother, which was portrayed as one of hostile-dependence.
Similarly, his relationship with his father had been quite distant. The
couple reported having been very satisfied with their marriage for many
years, but acknowledged growing apart in more recent years. They rarely
spent couples time together. They also admitted to growing marital tension
regarding parenting issues, particularly with regard to the degree to which
they needed to control their adolescent daughter’s behavior.
During family meetings, which included all four members, the therapist
worked to help family members share their feelings and concerns more openly
and direct]y, and listen to one another in a manner that communicated
respect and acceptance. Both father and Helena were able to express more
directly their pain about Helena’s grandmother’s death, and this enabled
Helena’s mother to disclose her distressing affects surrounding the death
of her own mother. The couples sessions had enabled the parents to begin to
talk more freely with one another, and as their connection strengthened,
they spontaneously began to share more time together. Concurrent with this,
Helena and Bruce were supported in disengaging from their parents’ martial
tension. Over the course of a few months, depressive symptoms were
ameliorated in all family members, and the family planned a vacation
together. In addition, the family began socializing more with other
families, and Helena gradually became more willing to engage with her
peers. As she did so, the conflicts regarding her parents’ difficulties in
letting her grow up came to the fore. The therapist helped the family
directly address these conflicts, supported the parents in setting
age-appropriate but realistic limits, and encouraged Helena to continue to
assert her independence in a respectful and healthy manner.
Depression affects all members of the family. When conceptualizing depression in a child, one must assume a developmental, systemic, and cultural framework in which the assessment and enhancement of attachment bonds in all family members is central. Similarly, when considering depression in adults, it is necessary to incorporate an attachment theory, interpersonal, and cultural perspective. Therefore, evaluation of a depressed child requires screening for depression in all family members (Ferro, Verdeli, Pierre, & Weissman, 2000). Similarly, assessment of a depressed parent warrants attention to the impact of parent psychopathology on family functioning (Dickstein, Seifer, Hayden, et al., 1998). The interventions outlined above are designed to alleviate depressive symptoms and prevent subsequent psychopathology through the development of secure attachments among all family members or through the reattachment process. Secure attachment relationships can serve as a buffer for psychological stressors throughout the lifespan because of the individual’s improved sense of self and ability to draw upon active support of family during times of future distress.
The area of attachment-based family therapy for depression can expand in a number of directions. First, our knowledge of the links between family attachment relationships and depression have received relatively little attention with regard to the directionality of the relation between attachment problems and depression, parenting issues associated with depressed fathers and two depressed parents, the contribution of depression in extended-family members, depression in older children/adolescents, and depression in teen mothers and their children. Second, more focus needs to be directed toward measuring both parental and child attachment styles within the same family. One reason that this has not occurred in more studies is that attachment interviews are tedious and time-consuming to administer and analyze, and typically require highly trained interviewers or observers. This virtually precludes their use in daily clinical practice. The same is true for structured psychiatric diagnostic interviews to evaluate for depression and comorbid conditions in children and adults. Third, more systematic intervention studies need to be conducted to ascertain the efficacy and effectiveness of various intervention models. While some of the approaches discussed have some empirical support, in general the sample sizes in these studies are small and the samples are homogeneous. For a number of the models discussed, no investigations have assessed their usefulness. Fourth, despite the fact that many of the intervention protocols call for the inclusion of all family members, the majority of the focus is on the depressed parent-child dyad and on the depressed child and his or her parents. There is limited discussion of ways to address siblings with no depressive symptoms or other forms of psychopathology, or the sibling subsystems in depressed families. Finally, few of the intervention protocols have been designed in a manner that is culturally competent or that takes into account the complexity of family typologies (e.g., blended families, intergenerational families, adoptive families).
Hopefully, the aforementioned developmentally informed review of attachment and depression, with a focus on depressed parents and depressed children, will heighten family therapists’ sensitivities to attending to depression and attachment relationships in all family members. We encourage family therapists working with depressed families to assume an attachment-based perspective, such that their interventions targeted developing and bolstering attachment relationships. Such work is likely to yield improvements in both overall family functioning and the adaptive capacities of each individual family member. In addition, the emphasis on the enhancement of attachment bonds is likely a critical component of insuring maintenance of treatment gains following treatment termination.
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Manuscript received August 2, 2001; revision submitted and accepted March 26, 2002.
MELISSA HERRING, Ph.D. [dagger]
NADINE J. KASLOW, Ph.D., ABPP [dagger]
[dagger] Melissa Herring, Ph.D., Postdoctoral Fellow (e-mail: firstname.lastname@example.org) and Nadine J. Kaslow, Ph.D., ABPP, Professor and Chief Psychologist (APPIC Chair and Division 43 President), are both affiliated with Emory University, Department of Psychiatry and Behavioral Sciences, Grady Health System, 80 Jessie Hill, Jr. Drive SE, Atlanta GA 30303. Send correspondence and reprint requests to Dr. Kaslow at the above address or e-mail: email@example.com.
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