Click here to contact Arthur and/or see his GoodTherapy.org Profile

There are a number of ways to think about Dyadic Developmental Psychotherapy. One way is to consider what are the essential components of this evidence-based, effective, and empirically validated treatment, which was developed by Dr. Daniel Hughes. The following list is a listing of what are some of these essential components. Future articles will describe these elements in more detail.

Main Components of Dyadic Developmental Psychotherapy:

• Therapist use of self
• Process focused: It’s about connections not compliance
• PLACE & PACE
• Intersubjectivity
• Reflective Capacity
• Affective/Reflective dialogue
• Commitment
• Insightfulness
• Coherent narrative
• Co-regulation of emotions
• Co-creation of meanings
• Follow-lead-follow
• Interactive repair
• Nonverbal-verbal dialogue

The basic principles of Dyadic Developmental Psychotherapy may be summarized in the following four paragraphs.

1. Both the caregivers’ and therapists’ own attachment strategies are organized and resolved before the onset of the child’s treatment. Previous research (Tyrell et al. 1999; Dozier et al. 2001) has shown the importance of the caregivers and therapists state of mind with respect to attachment for the success of treatment.

2. The therapist and caregiver provide the intersubjective experiences for the child that were seldom present in situations of abuse and neglect. These intersubjective experiences are characterized by shared emotion (attunement), shared awareness and attention, and complementary intentions. Intersubjective experiences are the primary means by which the infant and young child learn about self, other, and the world (Trevarthen 2001). Intrafamilial and Complex trauma will significantly disrupt the development of concordant intersubjectivity and increase the risk that the child will be unable to create a coherent meaning for many events, particularly traumatic ones. The therapist must provide intersubjective experiences for the parent that help create a secure base within which the parent, child, and therapist can co-create new and more therapeutic meanings for experiences.

Whenever possible, the child’s primary caregiver (biological, adoptive, or foster parent or primary caregiver in a residential setting) is an active participant in the session. The therapist must provide to the caregiver support and guidance in communicating thoughts, emotions, and intentions to their child. The primary caregiver serves as the primary source of safety, security, and comfort while the child explores events, experiences, and emotions that may generate fear and shame. The caregiver’s presence allows the therapist to facilitate the successful exploration and resolution of behavior problems in the home by modeling for the parent PACE as an effective means of achieving conflict resolution and increasing emotional and behavioral regulation within the home. The therapist will generally only see a child, usually a teenager, as an individual client when a primary attachment figure is not available. In these instances, the treatment will proceed at a markedly slower pace since the child is essentially emotionally alone the rest of the week in the process of integrating the therapeutic themes. The lack of a primary attachment figure is a severe impediment to creating the security and safety necessary for exploration and integration.

3. Use of PACE and PLACE. These acronyms describe the ‘attitude’ of the therapist and caregiver. PACE refers to the therapist setting a healing pace to treatment by being playful, accepting, curious and empathic. Through PACE, the therapist is able to both generate and regulate, through empathy (and playfulness when appropriate), the emerging emotion that is associated with the events being explored. The therapist is also able to facilitate an open, reflective attitude to reorganize the experience of these events through the therapists accepting and curious stance. PLACE refers to the parent creating a healing environment by being playful, loving, accepting, curious and empathic. All interventions are utilized within the context of PACE along with the other principles presented in this chapter. Any technique may lead to dysregulation if these basic principles, which are needed to generate general safety, are ignored. These ideas are described in more detail in Becker-Weidman & Shell (2005), Becker-Weidman & Shell (2010), and Hughes (2006, 2007).

4. The inevitable misattunements and conflicts that arise in relationships are directly addressed and repaired through the ongoing qualities of the relationship using PACE. The creation of concordant intersubjectivity facilitates the co-creation of meaning and the co-regulation of emotions. The need for interactive repair is especially important as the themes being explored are often characterized by shame and fear. Repair helps with both affect and behavioral regulation, and directly addresses the child’s convictions that the child must face stressful events alone, or that any conflict will lead to abandonment. The attachment figures – parent and therapist – are responsible for the initiation of repair, not the child. These same principles apply to the therapist-caregiver relationship. Inevitable misattunements between therapist and parent are directly addressed and repaired thought the relationship. It is the therapist’s responsibility to initiate the repair, not the parent.

©Copyright 2010 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

In the previous articles about Dyadic Developmental Psychotherapy I described the ten take-away points that I want therapists to take away from my Master Class, Level I, an Introductory courses in Dyadic Developmental Psychotherapy. I then described a few of these in detail. In this article I will describe several of the others.

1. It’s about connections not compliance.
2. Mistakes are not a problem, lack of repair is.

It’s About Connections not Compliance:

The “it” in this statement refers to what is important for parents and therapists to be attending to as they guide and help. Connections are most important. I am not saying that compliance isn’t important; far from the truth would that be. Compliance, values, ethics, adherence to rules, and related constructs are very important. The question is, “how to get compliance, values, ethics, adherence to rules, etc.?” While is certainly is true that you can get nearly anyone to do nearly anything if you exert enough force; that does not lead to internalization or to following the rules when the person exerting the force is not present. For example, when we put a car thief in jail, that person does not steal anymore cars; at least not while still in jail. But, what is the recidivism rate for car thieves is very high, over 50%. What parents want is for their child to internalize their values and beliefs and to “act good,” whether or not the parent is present and watching. The way to get compliance is through connections.

It is through a relationship that the child begins to internalize the parent’s values, beliefs, and ethics. A strong connection (or a healthy and secure pattern of attachment) can lead to the child internalizing the parent’s values, beliefs, and ethics. A strong connection can lead to the child wanting to please the parent, and compliance then follows. The child who has a strong positive connection and relationship with the parent wants to please the parent and feels good when the parent is happy with the child and the child’s behavior; this will lead to compliance.

A parent described the following story to me that exemplifies what I am talking about here. This family would use as a consequence the removal of “screens” (CRT’s TV, Videos, Games, Cell phone, Computer, etc) whenever their son misbehaved. When their twenty-two year old son, who by now was three inches taller and forty pounds larger than his father, was home from college one summer he did something that the father was not pleased with, so he said to his son, “That’s it, no screens for the weekend.” The young man looked at his father and said, “Can you do that?” to which the father replies, “Yes, I’m your father.” The parent described how for about half a minute he could see his son thinking something like, “oh, bummer, it’s gonna be a boring week; and I had plans too.” The father then realized that this wasn’t the best approach and he and his son had a chat about what the father was unhappy with. However, the parent was struck with how his son seemed willing to accept the “punishment.”

So, I am not saying, “don’t expect compliance.” What I am saying, is that it is through building a relationship, through connections, that real compliance is achieved.

Mistakes are not a Problem, Lack of Repair is:

Everyone makes mistakes. What is destructive is the lack of repair of the mistake. Repair involves accepting responsibility for having made a mistake and an apology of some sort. It is very important that therapists and parents be able to acknowledge when they have made an error and apologize for that mistake. This models openness and demonstrates how to recover and repair the relationship that was damaged by the mistake. What often prevents the repair of the relationship is the parent’s or therapist’s shame about what was done. Shame leads to hiding and acting as if nothing happened.

An example may help clarify this. I was seeing a mother and eight-year-old boy for the first or second time. The boy has a long and extensive history of maltreatment by his birth family and several subsequent foster families. He met the DSM-IV criteria for Reactive Attachment Disorder and Bipolar I disorder. He would often engage in self-injurious behaviors, such as picking at himself till he bled. We were talking about his birth family when I looked over (he was sitting to the left of me on the couch between me and his mother) and saw that he had picked his nose till it bled and was wiping it on my sleeve. I believe that it is the “job” of the therapist to manage the pace of the session and to keep everyone regulated. So, I looked over at John and said, “You don’t want to talk about this anymore?” He said, “No, I don’t.” I replied, “I’m sorry, I didn’t realize that sooner. We can talk about something else, then; what would you like to chat about?”

©Copyright 2010 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

In my previous article about Dyadic Developmental Psychotherapy, I described the ten take-away points that I want therapists to take away from my Master Class, Level I, and Introductory courses in Dyadic Developmental Psychotherapy. In that article I described the first of the ten take-away points: Kind Attributions. In this article I will describe a few of the others…

1. All behavior is adaptive.
a. Mental health is flexibility. Many children’s “problems” can be seen as caused by rigidity and not feeling safe.
b. Much of the child’s behavior can be explained by their being “relationship phobic.”

2. Strange or odd behavior represents our lack of empathy.
a. Is this a child who like to argue or a child who is fearful of being hurt, scared, hurt, and lacking trust?

In my previous article I stated, “All behavior is adaptive.” I then had two related points, which state mental health is flexibility and much of the child’s behavior can be explained by their being “relationship phobic.”

It is important to recognize that behavior patterns develop to serve a purpose and are adaptive in the environment within which the patterns emerge. As such, behavior that may appear “bizarre,” may be quite adaptive, but not in the current environment. For example, I was seeing a little girl, age nine, who would horde food. She would hide food under her mattress, in her pockets, even in her cheeks. When she ate, she would eat very fast and gorge herself; sometimes until she vomited. Her parents were disturbed and confused by this behavior. Food was never an issue in the family; they never used food as a reward or punishment. The behavior was mysterious, disturbing, and confusing. When asked about it, the girl could only say that she knew that she could have food at home when she wanted and that the family had enough food.

So, what is going on here? It turns out that the girl was in an orphanage for the first four years of her life. Despite five years in her new home, this pattern persisted. In thinking about her particular orphanage, it became clear that her behavior was quite adaptive and functional. In her orphanage in a rural section of Russia, food was often scarce and of poor quality. The bigger kids would take the food of the smaller children and the few staff present did not intervene. This child learned to eat fast and eat as much as possible; she never was sure when her next meal would occur or if someone would take her food. Hoarding food was a good response to this situation, as were her other behaviors. She had difficulty trusting and believing that her family would actually take care of her based on these early experiences. While she could say that she knew that her parents would always feed her and protect her, when in the moment, confronted with a situation that evoked the emotional responses from her orphanage days, she responded to those feelings not her cognitive thoughts.

In this child’s behavior we can see the other two points operating. The girl was acting as if she was back in the orphanage and not recognizing, emotionally, that her current environment was different from that past one. This is the same basis for flash-backs and related symptoms of Post-Traumatic-Stress-Disorder. In addition, her lack of trust in adults and wariness, which developed in response to the orphanage staff’s lack of providing a safe, secure, and responsive setting, led her to distrust carers…to act in a way that I described as “relationship phobic.” It did not occur to her that her parents would care for her and since her experiences with peers were negative as well; she was more comfortable with a large amount of emotional distance between herself and carers.

©Copyright 2010 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

In this article about Dyadic Developmental Psychotherapy I want to describe the ten take-away points that I want therapists to take away from my Master Class, Level I, and Introductory courses in Dyadic Developmental Psychotherapy. Once or twice a year I teach a six-month Master Class in Dyadic Developmental Psychotherapy that meets one Saturday a month for six months. This format allows therapists to learn the model and begin using and refining their use of the model in between sessions. When I teach this class across the US and Canada, I usually provide three two-day sessions separated by one to two months; again this allows therapists to practice and refine their competency over time. I’ve also have the privilege of teaching Level I and Introductory Dyadic Developmental Psychotherapy courses in Singapore, Finland, and the Czech Republic. In all instances I want the participants to come away understanding these ten points. I often introduce each one by saying, “If only take away one thing from this class, it’s this….” Of course, by the end of the class there are ten of these.

The Ten Take-Away Points:

1. Kind attributions.
2. All behavior is adaptive; a. Mental health is flexibility. Many children’s “problems” can be seen as caused by rigidity and not feeling safe; b. Much of the child’s behavior can be explained by their being “relationship phobic.”
3. Strange or odd behavior represents our lack of empathy; a. Is this a child who likes to argue or a child who is fearful of being hurt, is scared, and lacking trust?
4. It’s about connections, not compliance.
5. Mistakes are not a problem, lack of repair is.
6. Who owns the button?
7. Alliance is the key. Alliance is necessary to create a secure base, which is necessary too for exploration, integration, and healing.
8. Parents are the keystone.
9. How to stop a behavior? Treat the cause not the symptom. Address the underlying driver.
10. Shame, fear, anxiety underlie much.

I will describe the first of these points now and the balance in a future article that you will see here on GoodTherapy.org.

Kind Attributions:

Why did the parent or child do what they did? Our assumptions regarding motives and intentions of the other influence how we feel about that person and how we act toward that person. For example, how do you feel about an abusive parent? If you see that person as a monster, vicious, bad, you will feel and act in accordance with that assumption. In my experience, parents who have abused their children don’t intend to be hurtful, abusive, or neglectful. They often have significant trauma histories that impair their emotional, psychological, and interpersonal functioning. They often feel great shame over their actions. Viewing their behavior this way leads you to feel differently and in accordance with that view. To be therapeutic, we must build an alliance with the other person. Kind assumptions help.

What about a child who takes things that are not the child’s without asking; without permission? How do you feel about a liar and a thief? Warm and cuddly or annoyed, irritated, and distant? The attribution that the child is a liar and thief leads you to feel irritated and distant toward that child and to act accordingly. However, many children who have been experienced chronic early maltreatment within a caregiving relationship (Complex Trauma) have learned that adults are either non-responsive or hurtful and cannot be relied upon for help. These children have difficulty trusting and so they have difficulty seeing help when it is there. When these children experience a need or want, their emotions overwhelm their cognitive abilities and they act on their internal working model of the world; that no one will help you but yourself. So, the child take what the child needs without asking. The child who feels the world is a scary place and that carers cannot be trusted; who feels overwhelming shame later over the child’s actions and so hides by denying the child’s actions may evoke you empathy and caring.

So, as you see, your attributions regarding the other person profoundly influence how you feel about that person and then how you will act toward that person. To be therapeutic with parents and children we need to have kind attributions regarding their motives and motivations.

©Copyright 2009 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

Dyadic Developmental Psychotherapy, which is an evidence-based, effective, and empirically validated treatment is composed of a variety of elements and based on a number of principles that have strong empirical support. Dyadic Developmental Psychotherapy is, in some respects, an amalgam of effective principles of treatment. This article will describe the elements of Dyadic Developmental Psychotherapy and a few of its underlying principles.

It is helpful to remember that everything begins with building an alliance. “Without an alliance there can be no secure base. Without a secure base there can be no exploration. Without exploration there can be no integration. Without integration there can be no healing.”

Safety is the first principle of treatment. Without safety (physical, psychological, relational, and emotional) nothing else can happen. So creating and ensuring safety comes first. Safety is provided for a child by a caregiver who is…

1. Available
2. Sensitive
3. Responsive to the child’s needs
4. Able to provide Interactive Repair
5. Insightful
6. Reflective

Intersubjectivity is a central concept in Dyadic Developmental Psychotherapy. Once safety is provided and maintained, and the safe base created, the child can begin to explore, learning primarily from the child’s parents’ experience of the child and of the world. Intersubjectivity is a reciprocal process. It can be concordant or discordant. Intersubjectivity is composed of the following three elements:

1. Shared emotion (attunement)
2. Shared attention and joint awareness
3. Share intention; cooperation and collaboration

Shared Emotion: Children who have difficulty regulating their emotions cannot do this on their own. They need a sensitive and responsive parent who can do this for them and then with them so that the child can internalize this capacity. This co-regulation of affect is necessary if the child is to be able to explore past traumas that may generate anxiety or shame.

Shared Attention: This is a reciprocal taking turns. There is an interest in the other’s experiences and a common attention to what is occurring now.

Shared Intentions: This refers to the enjoyment of shared experiences and being together. It involves getting to know each other and the other’s experience, feelings, and perceptions.

Another central element of Dyadic Developmental Psychotherapy is the affective-reflective dialogue. This refers to a “conversation” that includes emotions and reflection on the self, other, and the relationship. Self-aware reflection is a cornerstone of healing.

The practice of Dyadic Developmental Psychotherapy involves and recognizes the importance of the co-creation of meaning. Often what makes trauma traumatic is not the objective facts, but the meaning we ascribe to those events. What experiences mean create the emotions we experience and then lead to the behaviors we exhibit. In treatment we join our experience of an event with the child’s experience of that event and reflect on the similarities and differences of our experiences. This reflection of the implications of other ways to experience events, past and present, can lead to new affect and new modes of behavior.

Self-aware reflection, the reflective function, is another key element of Dyadic Developmental Psychotherapy. It involves “the thinking mind” with regard to the inner world of self and other. This leads to greater understanding and greater flexibility in responses available. When parents have a well developed reflective function, this leads to the child experiencing that they exist in a positive way in the heart and mind of the parent. New meanings lead to new options for action that leads to healthier functioning.

Interactive repair happens in treatment and at home. It is the reestablishment of the relationship and the reestablishment of concordant intersubjectivity following some conflict, separation, mistake, or other breach in the relationship. This highlights the importance of the relationship and that mistakes can be repaired. It is primarily the adult’s responsibility to make this happen.

In a future article I will describe the stages of treatment and other aspects of Dyadic Developmental Psychotherapy that make this an effective treatment.

©Copyright 2009 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

In this first article here I will describe what Dyadic Developmental Psychotherapy is. Dyadic Developmental Psychotherapy began as a family-therapy approach, grounded in attachment theory, for the treatment of children with disorders of attachment. It has developed over the past decade into a broader approach for treatment and has been found to be an evidence-based, effective, and empirically validated treatment.

Dyadic Developmental Psychotherapy has as its central therapeutic mechanism the maintenance of a contingent, collaborative, sensitive, reflective and affectively attuned relationship between therapist and child, between caregiver and child, and between therapist and caregiver. Dyadic Developmental Psychotherapy focuses on and relies upon the intersubjective sharing and joint development and organization of emotional experience. Intersubjectivity refers to shared emotion (also called attunement), shared attention, and shared intention.

A few basic principles of Dyadic Developmental Psychotherapy:

1. Confidence that both the caregivers’ and therapists’ own attachment strategies are organized and resolved must be present before involving the child in the therapy. Previous research (Tyrell et al. 1999; Dozier et al. 2001) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. The therapist and caregiver provide intersubjective experiences for the child that are positive, concordant, and healing. These intersubjective experiences are characterized by shared affect (attunement), joint focus of awareness and attention, and complementary intentions. Intrafamilial trauma will significantly disrupt the development of intersubjectivity and increase the risk that the child will be unable to create a coherent meaning for many events and especially traumatic ones.

3. Use of PACE and PLACE. These acronyms describe the ‘attitude’ of the therapist and caregiver. PACE refers to the therapist setting a healing pace to therapy by being playful, accepting, curious and generate and regulate through empathy (and playfulness when appropriate), the emerging affect that is associated with events being explored. The therapist is also able to facilitate an open, reflective attitude to reorganizing the experience of these events through her accepting and curious stance. PLACE refers to the parent creating a healing environment by being playful, loving, accepting, curious and empathic. These ideas are described more fully in Becker-Weidman & Shell (2005) and Hughes (2006, 2007).

4. The inevitable misattunements and conflicts that arise in interpersonal relationships are directly addressed and then repaired through the ongoing qualities of the relationship (PACE). The need for interactive repair is especially important as the themes often being explored are often characterized by shame and fear. Repair helps with both affect regulation and directly addresses the child’s convictions that he must face stressful events alone, or that any conflict will lead to abandonment. The attachment figures – parent and therapist – are responsible for the initiation of repair, rather than the child.

In my next article, I will describe some of the interventions and methods of this treatment. Your comments and questions are welcome.

References

Becker-Weidman, A., (2004) “Dyadic Developmental Psychotherapy,” in Attachment Disorder Resource Book, As Simple As That Foundation, August 2004.

Becker-Weidman, A., (2005) “Dyadic Developmental Psychotherapy: A multi-year follow-up…Preliminary Summary Findings,” Connections, June 2005.

Becker-Weidman, A., & Shell, D., (Eds.) (2005, Reprinted 2008) Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders. Woods N Barnes publishing, Oklahoma City, OK, 2005.

Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, pp 147-171.

Becker-Weidman, A., (2006) Dyadic Developmental Psychotherapy: A multi-year Follow-up, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43-60.

Becker-Weidman, A., (2006) Principles of Attachment Parenting, 3 DVD set.

Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” http://www.center4familydevelop.com/research.pdf

Becker-Weidman, A., (2008) “Treatment for Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy” Child and Adolescent Mental Health Volume 13, No. 1, 2008, pp. 52-60.

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Family Social Work, 13, pp.329-337.

Becker-Weidman, A., & Shell, D., (in press), Attachment Parenting: Developing Connections and Healing Children.

Cook, A., Blaustein, M., Spinazolla, J. & van der Kolk, B. (2003) Complex Trauma in Children and Adolescents. White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. National Center for Child Traumatic Stress, Los Angeles, CA.

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M. et al. (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390–398.

Craven, P. & Lee, R. (2006) Therapeutic interventions for foster children: a systematic research synthesis. Research on Social Work Practice, 16, 287–304.

Hughes, D. (2004) An attachment-based treatment of maltreated children and young people. Attachment and Human Development,6, 263–278.

Hughes, D. (2005) The development of Dyadic Developmental Psychotherapy. In: Creating Capacity for Attachment (eds A.Becker-Weidman & D. Shell), pp. vii–xvii, Wood N Barnes, Oklahoma City, OK.

Hughes, D. (2006) Building the Bonds of Attachment, 2nd edn. Jason Aronson, Lanham, MD.

Hughes, D. (2007) Attachment-Focused Family Therapy. W.W. Norton, NewYork.

Hughes, D., (2008) Attachment-Focused Parenting. Norton, NY.

©Copyright 2009 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile

Click here to contact Arthur and/or see his GoodTherapy.org Profile

Many adopted and foster children have had very difficult and painful histories with their first parents. These children have experienced chronic early maltreatment within a caregiving relationship. Such a history can lead to the development of Complex Trauma (Cook et. al., 2003; Cook et. al., 2005), disorders of attachment, and Reactive Attachment Disorder. Children with histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, are at risk of developing severe psychiatric problems (Gauthier, Stollak, Messe, & Arnoff, 1996; Malinosky-Rummell & Hansen, 1993). These children are likely to develop Reactive Attachment Disorder (Greenberg, 1999; Lyons-Ruth & Jacobvitz, 1999). Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms (Carlson, Cicchetti, Barnett, & Braunwald, 1995; Cicchetti, Cummings, Greenberg, & Marvin, 1990). Many of these children are violent (Robins, 1978) and aggressive (Prino & Peyrot, 1994) and as adults are at risk of developing a variety of psychological problems (Schreiber & Lyddon, 1998) and personality disorders, including antisocial personality disorder (Finzi, Cohen, Sapir, & Weizman, 2000), narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder (Dozier, Stovall, & Albus, 1999). Therapeutic Parenting is often necessary to help these children heal (Becker-Weidman, A., & Shell, D., 2005/2008). This approach to parenting is often not familiar to most parents and requires a significant amount of work and preparation. Attachment facilitating parenting is grounded in attachment theory and is based on a set of principles that include:

• Sensitivity
• Responsiveness
• Following the child’s lead
• The sharing of congruent intersubjective experiences
• Creating a sense of safety and security

The effective implementation of these principles requires parents who:

• Are strongly committed to the child.
• Have well developed reflective abilities
• Have good insightfulness
• Have a relatively secure state of mind with respect to attachment

This type of parenting is consistent with Dyadic Developmental Psychotherapy, which is an evidence-based and effective treatment for children with trauma and attachment disorders (Becker-Weidman & Hughes, 2008). Many foster and adoptive parents find their children’s behaviors strange, frightening, disturbing, and upsetting. They often don’t understand why their child behaves as the child does; “after all, my child is now safe, doesn’t he get it?” It can be difficult to appreciate the depth and pervasiveness of the damage caused by earlier maltreatment.

Therapeutic parenting based on Dyadic Developmental Psychotherapy relies of helping parents understand what is causing the child’s behaviors. Looking deeper in order to understand what is motivating the child. All behavior is adaptive and functional; however sometimes the behaviors that were adaptive in one environment are ill-suited for the new home. If your first parents were neglectful, unreliable, and inconsistent so that you were often hungry and left alone for long periods of time, hoarding food, gorging, and going to “anyone” for help is adaptive. When that child is placed in a foster or adoptive home with caring, responsive, sensitive parents, that same behavior is no longer adaptive. By understanding what is driving the behavior and appreciating the child’s fear, anxieties, shame, and anger, the new parent will be better able to respond to the emotions driving the behavior rather than the surface behavior or symptoms. Unless the underlying emotions are addressed with sensitivity and within a safe, unconditionally loving, and supportive home, the behavior or symptoms are not likely to stop…they may change into other problems, but if the underlying cause remains, then the problems will surface again and again.

Let’s discuss the principles required. These principles are more fully elaborated elsewhere (Becker-Weidman & Shell, 2005; Becker-Weidman, 2007)

Sensitivity

Because children with trauma and attachment disorders are often unable to describe their internal states, emotions, or thoughts, it becomes the job of the parent to do this with and for the child so that the child learns to do this. Of course, this is precisely what one does with a newborn, toddler, and child. We often help children manage their internal states by doing that with them. When a baby cries, we pick up the baby, comfort the child, and by so doing, regulate the child’s level of arousal. Over time the infant becomes increasingly proficient at doing this independently. The parent of a foster or adopted child must be sensitive to the internal states of their child so that the parent can respond to the underlying emotions driving behavior.

Responsiveness

Once the underlying emotion is identified, the parent must respond to this need or emotion, with sensitivity. By meeting the child’s need (to feel safe, loved, cared about, for food, drink, joy, etc) the child will internalize new and healthier models of relationships and parents.

Following the Child’s Lead

By this I mean that the parent will need to respond to the child and follow the child’s lead in the sense of providing what the child is needing (comfort, affection, support, structure, etc) and at the child’s pace. It is very important to move at the child’s pace to create the necessary sense of safety and security that these children need.

The Sharing of Congruent Intersubjective Experiences

Intersubjectivity refers to shared emotion (also called attunement), share attention, and share intention. You can understand this if you think of playing a board game with your child. When you are playing some game together and enjoying the experience, you are sharing emotions (joy and a sense of competence), sharing attention (focusing on the game), and sharing intention (playing by the rules, both trying to win, having fun, etc.). Or another example, when talking about the death of the child’s loved grandparent, you both may share the same emotions (grief), both are recalling memories of the grandparent (shared intention and attention). It is the sharing of congruent intersubjective experiences, experiences in which all three elements are the shared, that helps the child heal and learn about intimacy and relationships.

Creating a Sense of Safety and Security

Safety comes first. Unless the child is physically, emotionally, and psychologically safe, healing cannot occur. So, it is the job of the parent to create safety and security for the child. This then allows for the exploration of underlying feelings, thoughts, and memories. Without an alliance there can be no secure base. Without a secure base there can be no exploration. Without exploration there can be no integration. Without integration there can be no healing.
Unless the child feels safe, exploration is not possible.

So, what sort of parent is needed? We know form extensive research, that one of the best predictors of placement stability is the parent’s commitment to the child (Dozier, Grasso, Lindhiem, & Lewis, 2007). Therefore, building or rebuilding parental commitment is an important first step. Unless there is strong commitment, the child cannot feel safe and, as discussed above, safety is the most important first step in helping a hurt child heal.

Reflective capacity is also vital to placement stability and to the healing of adopted and foster children. The parent must be able to reflect on the child’s underlying emotions, how the past may be re-enacted in the present, and what in the parent’s own past is being triggered by the child. A well developed reflective function is necessary if the parent is to respond to the child in a healthy and healing manner. We all have buttons. The job of the therapeutic parent is to understand one’s buttons so that these can be disconnected so that when pushed, nothing happens.

Insightfulness (Koren-Karie, Oppenheim, Dolev, Sher, & Etzion-Carasso, 2002; Oppenheim, Koren-Karie, & Sagi, 2001; Oppenheim, & Koren-Karie, 2002; Oppenheim, Goldsmith, & Koren-Karie, 2005) is related to reflective capacity.

A parent’s state of mind with respect to attachment is the best predictor of the child’s. (Main, & Cassidy, 1988; Main, & Hesse, 1990). If the parent has a Secure state of mind with respect to attachment, then the adopted or foster child is more likely to develop a healthy and secure pattern of attachment and heal (Steele, Hodges, Kaniuk, Steele, Hillman, & Asquith, 2008). We know that when young children are placed in a foster home, the child will begin to develop a pattern of attachment that is the same as the foster parent’s state of mind with respect to attachment (Dozier, Stovall, Albus, & Bates, 2001). Obviously, in older children, this is a more difficult task. In the general population, about 60% of the adults have a secure state of mind with respect to attachment. For parents who have an insecure state of mind with respect to attachment, they can still learn to parent effectively with help (Becker-Weidman, A., & Shell, D., 2005/2008; Bick & Dozier, 2008).

Useful Resources for Parents

Becker-Weidman, A., (2007). Principles of Attachment Parenting. 3-set DVD. Williamsville, NY: Center for Family Development.

Becker-Weidman, A., & Shell, D., (Eds.) (2005/2008) Creating Capacity for Attachment, Oklahoma City, OK: Wood N Barnes/ Williamsville, NY: Center For Family Development.

Golding, K., (2008). Nurturing Attachments. London: Jessica Kingsley.

Hughes, D. (2006) Building the Bonds of Attachment, 2nd edition, Jason Aronson, Lanham, MD. .

Siegel, D., & Hartzell, M., (2003). Parenting from the Inside out. Tarcher.

References

Becker-Weidman, A., & Shell, D., (Eds.) (2005, 2008). Creating Capacity for Attachment, Oklahoma City, OK: Wood N Barnes & Williamsville, NY: Center for Family Development.

Becker-Weidman, A., (2007). Principles of Attachment Parenting. 3-set DVD. Williamsville, NY: Center for Family Development.

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337.

Bick, J., & Dozier, M., (2008). Helping Foster Parents Change. In H. Steele & M. Steele (Eds.), Clinical Applications of the Adult Attachment Interview (pp. 452-471). NY: Guilford.

Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135–157). NY: Cambridge University Press.

Cicchetti, D., Cummings, E. M., Greenberg, M. T., & Marvin, R. S. (1990). An organizational perspective on attachment beyond infancy. In M. Greenberg, D. Cicchetti & M. Cummings (Eds.), Attachment in the preschool years (pp. 3–50). Chicago: University of Chicago Press.

Cook, A., Blaustein, M., Spinazolla, J. & van der Kolk, B. (2003) Complex Trauma in Children and Adolescents. White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. National Center for Child Traumatic Stress, Los Angeles, CA.

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M. et al. (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390–398.

Dozier, M., Stovall, K., Albus, K., & Bates, B. (2001). Attachment for infants in foster care: The role of caregiver state of mind. Child Development, 72, 1467-1477.

Dozier, M., Grasso, D., Lindhiem, O., & Lewis, E., (2007) “The role of caregiver commitment in foster care,” in D. Oppenheim & D. Goldsmith, (Eds.) Attachment Theory in Clinical Work with Children. NY: Guilford.

Dozier, M., Stovall, K. C., & Albus, K. (1999). Attachment and psychopathology in adulthood. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 497–519). NY: Guilford Press.

Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment styles in maltreated children: A comparative study. Child Development and Human Development, 31, 113–128.

Gauthier, L., Stollak, G., Messe, L., & Arnoff, J. (1996). Recall of childhood neglect and physical abuse as differential predictors of current psychological functioning. Child Abuse and Neglect, 20, 549–559.

Greenberg, M. (1999). Attachment and psychopathology in childhood. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 469–496). NY: Guilford Press.

Koren-Karie, N., Oppenheim, D., Dolev S., Sher, E., & Etzion-Carasso, E. (2002). Mothers’ insightfulness regarding their infants’ internal experience: Relations with maternal sensitivity and infant attachment. Developmental Psychology, 38, 534-542.

Lyons-Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence and lapses in behavioral and attentional strategies. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 520–554). NY: Guilford Press.

Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age six: Predictable from infant attachment classifications and stable over a one-month period. Developmental Psychology, 24, 415–426.

Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant disorganized attachment status. In M. T. Greenberg, D. Ciccehetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 161–184). Chicago: University of Chicago Press.

Malinosky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114, 68–69.

Oppenheim, D., Koren-Karie, N., & Sagi, A. (2001). Mothers’ empathic understanding of their preschoolers’ internal experience: Relations with early attachment. International Journal of Behavioral Development., 25, 16-26.

Oppenheim, D. & Koren-Karie, N. (2002). Mothers’ Insightfulness Regarding their Children’s Internal Worlds: The capacity underlying secure child-mother relationships. Infant Mental Health Journal, 23(6), 593-605.

Oppenheim, D., Goldsmith, D., & Koren-Karie, N. (2005). Maternal Insightfulness and preschoolers’ emotion and behavior problems: Reciprocal influences in a day-treatment program. Infant Mental Health Journal.

Prino, C. T., & Peyrot, M. (1994). The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior. Child Abuse and Neglect, 18, 871–884.

Robins, L. N. (1978). Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior. Psychological Medicine, 8, 611–622.

Schreiber, R., & Lyddon, W. J. (1998). Parental bonding and current psychological functioning among childhood sexual abuse survivors. Journal of Counseling Psychology, 45, 358–362.

Steele, M., Hodges, J., Kaniuk, J., Steele, H., Hillman, S., & Asquith, K., (2008). Forcasting Outcomes in Previously Maltreated Children. In H. Steele & M. Steele (Eds.), Clinical Applications of the Adult Attachment Interview (pp. 427-452). NY: Guilford.

©Copyright 2009 by Arthur Becker-Weidman, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile