Dyadic developmental psychotherapy

Dyadic developmental psychotherapy is an evidence-based treatment(1) approach for the treatment of attachment disorder, reactive attachment disorder, and complex trauma. Children who have experienced pervasive and extensive trauma, neglect, loss, and/or other dysregulating experiences can benefit from this treatment. Dyadic Developmental Psychotherapy is based on principles derived from Attachment theory and Research; see the work of Bowlby. The treatment is firmly grounded in the work of Bowlby. The treatment meets the standards of the American Professional Society on Child Abuse, The American Academy of Child Psychiatry, American Psychological Association, American Psychiatric Association, National Association of Social Workers, and various other groups' standards for the evaluation and treatment of children and adolescents. This is a non-coercive treatment. The principles and methodology of Dyadic Developmental Psychotherapy are based on long-standing treatment principles with very strong empirical evidence and a long history of proven efficacy.

Dyadic Developmental Psychotherapy is an effective and evidence-based treatment developed by Daniel Hughes, Ph.D., (Hughes, 2005, Hughes, 2004, Hughes, 2003; Hughes, 1997)(13-15). Its basic principles are described by Hughes (2003) and summarized as follows:

A focus on both the caregivers' and therapists' own attachment histories. Previous research (Dozier, 2001,(16) Tyrell 1999 (17)) has shown the importance of the caregivers' and therapists' state of mind for the success of interventions.
Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.
Sharing of subjective experiences.
Use of PACE (Playfulness, Acceptance, Curiosity and Empathy) and PLACE (Playful, Loving, Accepting, Curious, and Empathic) strategies are essential to healing.
Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.
Caregivers use attachment-facilitating interventions.
Use of a variety of interventions, including cognitive-behavioral strategies.

PACE refers to the therapist setting a healing pace by being playful, accepting, curious, and empathic. PLACE refers to the parent creating a healing environment by being playful, loving accepting, curious, and empathic. These ideas are described more fully below.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines (Becker-Weidman & Shell, 2005). Attachment theory, developed by Bowlby (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. It relies on sound treatment principles based on empirical evidence, such as the importance of empathy, reflective function, and other general treatment principles.

This treatment has been found to produce measurable and sustained improvement in children diagnosed with Reactive Attachment Disorder (Becker-Weidman, 2006)(12). In that study it was found that other forms of treatment, such as individual therapy or play therapy did not produce any improvement; thus indicating that Dyadic Developmental Psychotheray is effective while other forms of treatment are not effective for this disorder. Dyadic developmental psychotherapy involves creating a safe setting in which the client can begin to explore, resolve, and integrate a wide range of memories, emotions, and current experiences, that are frightening, stressful, avoided or denied. Safety is created by insuring that this exploration occurs with nonverbal attunement, reflective, non-judgmental dialogue, along with empathy and reassurance. As the process unfolds, the client is creating a coherent life story or autobiographical narrative that is crucial for attachment security and is a strong protective factor against psychopathology. Therapeutic progress occurs within the joint activities of co-regulating affect and co-constructing meaning.

Evidence Base

Dyadic Developmental Psychotherapy has been shown to be an effective treatment for children with Reactive Attachment Disorder. One study(1) found that children who received Dyadic Developmental Psychotherapy had clinicially and statistically significant improvements in their functioning as measured by the Child Behavior Checklist (Achenback), while the children in the control group showed no change one year after treatment ended.

This study examined the effects of Dyadic Developmental Psychotherapy on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. Seven hypotheses were explored. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These findings continued for an average of 1.1 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 1.3 years after the evaluation was completed. The results are particularly salient since 82% of the treatment-group subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 53% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.

This study supports several of O’Connor & Zeanah’s conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.” The results of this study are a beginning toward that end. While there are a number of limitations to this study, given the severity of the disorders in question, the paucity of effective treatments, and the desperation of caregivers seeking help, it is a step in the right direction. Dyadic Developmental Psychotherapy is not a coercive therapy, which can be dangerous. Dyadic Developmental Psychotherapy provides caregiver support as an integral part of its treatment methodologies. Finally, Dyadic Developmental Psychotherapy uses a multimodal approach built around affect attunement.

This study suggests that Dyadic Developmental Psychotherapy is an effective intervention for children with trauma-attachment problems.

A second study (Becker-Weidman, 2006b in Sturt, 2006) continued following these children for four years after treatment ended. This study examined the effects of Dyadic Developmental Psychotherapy four years after treatment ended on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These findings continued for an average of 3.9 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 3.3 years after the evaluation was completed. The results are particularly salient since 82% of the treatment-group subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 100% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.

The basic principles of Dyadic Developmental Psychotherapy are grounded in well established treatment principles for the treatment of complex trauma:

Safety
Self-regulation
Self-reflective information processing
Traumatic experiences integration
Relational engagement
Positive affect enhancement

(See Cook et. al., "Complex Trauma in Children and Adolescents" Psychiatric Annals 35:5 May 2005 and Principles of Trauma Therapy by John Briere & Catherine Scott, Sage, NY 2006 for further details).

Attunement

Attunement is an essential component of this treatment. Nonverbal attunement refers to the frequent interactions between a parent and infant, in which both are sharing affect and focused attention on each other in a way such that the child's enjoyable experiences are amplified and his/her stressful experiences are reduced and contained. This is done through eye contact, facial expressions, gestures and movements, voice tone, timing and touch. These same early attachment experiences, which are fundamental for healthy emotional and social development, are utilized in therapy to enable to the client to rely on the therapist to regulate emotional experiences and to begin to understand these experiences more fully. Such understanding develops further through engaging in a conversation about these experiences, without judgment or criticism. The therapist will maintain a curious attitude about the memories and behaviors, encouraging the client to explore them to better understand their deeper meanings in his life and gradually develop a more coherent life-story. This process may be stressful for the client, so the therapist will frequently "take a break" from the work, provide empathy for the negative emotion that may be elicited, and reassure the client about his efforts and the therapeutic relationship.

The primary therapeutic attitude demonstrated throughout the sessions is one of PACE.

For the purpose of increasing the client's safety, his/her readiness to rely on significant attachment figures in his life, and his/her ability to resolve and integrate the dysregulating experiences that are being explored, a person who an important attachment figure to the client will be actively present. When the client is a child, this most often will be the child's parent or guardian. When the client is an adult, this most often will be the adult's partner.

Role of parents in treatment

The role of the parent in his/her child's psychotherapy is the following:

Help him to feel safe.
Create a healing PLACE, both nonverbally and verbally.
Help him to regulate any negative affect such as fear, shame, anger, or sadness.
Validate his/her worth in the face of trauma and shame-based behaviors.
Reassure him/her that your relationship remains strong regardless of the issues.
Help him/her to make sense of his/her life so that it is organized and congruent.
Help him/her to understand your perspective and motives with respect to him/her.

The parent's role is not to criticize, lecture, nag, or amplify shame. Periodic confrontation may be necessary and needs to be integrated into the overall treatment session. Reassurance and repair of the relationship after confrontation is crucial. The child will not participate fully in therapy, and will not benefit much from the process if s/he does not feel safe in a setting primarily characterized by PACE.

Frequently a person's symptoms are his/her unsuccessful ways of regulating frightening or shame-based memories, emotions, and current experiences. Angrily telling a person to stop engaging in these symptoms may actually increase their underlying causes. In helping the child in therapy and at home to regulate the affect associated with the symptoms, and to understand the deeper meanings of the symptoms, we are increasing the likelihood that the symptoms will decrease. At the same time it may certainly be necessary to address the symptoms through increased supervision or through applying natural consequences for them. Again, however, the issues will be addressed more effectively when done with PACE rather than habitual anger, rejection, or other shame-inducing actions.

When we are asking a client to address frightening or shame-based memories, emotions, and current experiences, when are asking him/her to engage in an activity that will be emotionally painful. In do so it is crucial that we maintain an attitude characterized by PACE in order to insure that the client is not alone while entering that painful experience. The client has developed significant symptoms and defenses against that pain, most often because s/he was alone in facing it. When we help to carry and contain the pain with him/her, when we co-regulate it with him/her, we are providing him/her with the safety needed to explore, resolve, and, integrate the experience. We do not facilitate safety when we support a client's avoidance of the pain, but rather when we remain emotionally present when he is addressing the pain.

Features of Dyadic Developmental Psychotherapy

The following statements reflect routine features of dyadic developmental psychotherapy:

Playful interactions, focused on positive affective experiences, are never forgotten as being an integral part of most treatment sessions, when the client is receptive. When the client is resistant to these experiences, the resistance is met with PACE.
Shame is frequently experienced when exploring many experiences of negative affect. Shame is always met with empathy, before considering interventions to question it.
Emotional communication that combines nonverbal attunement and reflective dialogue and is followed by relationship repair when necessary is the central therapeutic activity.
While supporting the reduction of shame, we also support the increase of guilt.
Resistance is met with PACE, rather than being criticized and/or punished.
Treatment is directive and client-centered. Directives are frequently modified, delayed, or set aside in response to resistance which is met with PACE.

Dyadic developmental psychotherapy involves the process having a conversation with the client and his/her attachment figure about a wide range of memories, emotions, and current experiences. This conversation occurs within the safety created by nonverbal attunement, reflective dialogue, and interactive repair.

The purpose of this dyadic conversation is to facilitate the development of a coherent autobiographical narrative that involves:

Co-regulation of affect elicited during the conversation.
Dyadic construction of meaning regarding the focus of the conversation.
Development of a sense of efficacy regarding being able to have a conversation about the full range of experiences, memories and emotions in one's personal narrative.

To facilitate this process the therapist will consisting maintain an attitude that involves communicating Playfulness, Acceptance, Curiosity and Empathy (PACE).

Stages of dyadic developmental psychotherapy

Discovery of Process: Provide Information and Experience.
Ambivalence about Process: Conversation about certain experiences, memories, and emotions are consistently avoided. Conversation reduces loneliness, confusion, and shame, while eliciting fear of vulnerability, dependence, and inadequacy.
Trust of Process: Client is beginning to experience improved abilities to co-regulate affect, to co-create meanings and representations, and to establish a sense of efficacy for establishing a coherent narrative and secure attachments.
Utilization of Process: Client is beginning to engage in similar conversations with significant attachment figures outside of therapy.

References

"Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 13(2), April 2006.
Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, OK: 2005. ISBN 1885473729
(O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
Hughes, Daniel, (2006) Building the Bonds of Attachment, 2nd edition, NY: Guilford Press.
Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.
Sturt, SM (Ed) (2006) New Developments in Child Abuse Research Nova Science Publishers, NY. ISBN 159454980
Bowlby, J. (1969,1982) Attachment 1 of Attachment and Loss. London: Hogarth Press; New York, Basic Books; Harmondsworth, UK: Penguin (1971). ISBN 0465005438.
Bowlby, J. (1973) Separation: Anxiety & Anger 2 of Attachment and Loss. London: Hogarth Press; New York: Basic Books; Harmondsworth: Penguin (1975). ISBN 0465097162.
Bowlby, J. (1980) Loss: Sadness & Depression 3 of Attachment and Loss. London: Hogarth Press; New York: Basic Books; Harmondsworth: Penguin (1981). ISBN 0465042376.
Bowlby, J. (1988) A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0415006406.
Bretherton, I. (1992) "The origins of attachment theory". Developmental Psychology, 28:759-775.
Holmes, J. (1993) John Bowlby and Attachment Theory. London: Routledge. ISBN 041507729X.
Becker-Weidman, A., (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova.
Cook et. al., "Complex Trauma in Children and Adolescents" Psychiatric Annals 35:5 May 2005
Briere, J., & Scott, C., (2006) Principles of Trauma Therapy NY: Sage.

External links

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