Dyadic Developmental Psychotherapy
February 21st, 2008 | Email this to your Friendsby Arthur Becker-Weidman, Ph.D.
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Dyadic Developmental Psychotherapy is a treatment approach to trauma, neglect, loss, and/or other dysregulating experiences that is based on principles derived from Attachment Theory and Research.
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 which 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.
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 playfulness, acceptance, empathy and curiosity (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.
The role of the parent in his/her child’s psychotherapy is the following:
1.Help him to feel safe.
2.Create a healing PLACE (Playful, Loving, Accepting, Curious, and Empathic), both nonverbally and verbally.
3.Help him to regulate any negative affect such as fear, shame, anger, or sadness.
4.Validate his/her worth in the face of trauma and shame based behaviors.
5.Reassure him/her that your relationship remains strong regardless of the issues.
6.Help him/her to make sense of his/her life so that it is organized and congruent.
7.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.
The following statements reflect routine features of DYADIC DEVELOPMENTAL PSYCHOTHERAPY:
1.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.
2.Shame is frequently experienced when exploring many experiences of negative affect. Shame is always met with empathy, before considering interventions to question it.
3.Emotional communication that combines nonverbal attunement and reflective dialogue and is followed by relationship repair when necessary is the central therapeutic activity.
4.While supporting the reduction of shame, we also support the increase of guilt.
5.Resistance is met with PACE, rather than being criticized and/or punished.
6.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: a. Co regulation of affect elicited during the conversation. b. Dyadic construction of meaning regarding the focus of the conversation. c. 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).
©Copyright 2008 by 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.
February 22nd, 2008 at 5:53 am
I am very much in agreement w/ this line of therapy, but am confused by this statement:
4.While supporting the reduction of shame, we also support the increase of guilt.
How is this helpful?
February 22nd, 2008 at 5:55 am
Yes, I was struck by that one as well.
I think that including playfulness is very helpful with children. How do you find adults reacting to this sort of thing in therapy?
Is this sort of therapy possible if the caregiver is no longer in the adult’s life?
February 22nd, 2008 at 5:57 am
I would love to hear some case studies involving this therapy. Do you know of a resource such as this? What sorts of issues are the most responsive to this sort of therapy? What is the average length of time for Dyadic Development Therapy?
February 22nd, 2008 at 11:52 am
Mary, What a great question. The idea, not explained in the article, has to do with child development and shame and guilt. If you recall Erikson’s stages, shame is a part of the second stage and guilt comes later. Shame is an isolating emotion and has to do with feeling that you are bad. When people feel shame, they hide (think of the toddler who does something “wrong.”) Guilt is a more connecting emotion and has to do with feeling that what you did was bad; although you can still feel that you are good. This leads to wanting to “fix” the error.
The idea here is that many children with histories of chronic early maltreatment within a care-giving relationship feel overwhelming shame (not guilt). By reducing the shame stemming from having been maltreated, the child moves, developmentally speaking, to the next stage, feeling guilt.
Niels,
Parents of children generally react quite well to this in treatment. For example, Theraplay is a modality that uses play extensively with good results.
All children have caregivers (birth family, foster family, or child-care staff in residential programs).
February 22nd, 2008 at 1:14 pm
Jesse,
A good resource to learn more about Dyadic Developmental Psychotherapy and to read a therapy transcript and other material is Creating Capacity for Attachment edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, 2005, Wood N Barnes, Oklahoma City, OK.
There have been a few empirical studies demonstrating the effectiveness of this approach with adopted and foster children who have Reactive Attachment Disorder. It is an approach that can also be used with persons who have experienced trauma and other disorders of attachment and as a more general approach to treatment (See Attachment focused Family therapy by Daniel Hughes, Ph.D., 2007).
March 2nd, 2008 at 5:25 pm
Jesse,
Two empirical studies in professional peer reviewed journals that you may also want to take a look at that demonstrate the effectiveness of this approach (when compared with “usual care,”) are:
Becker-Weidman, A., (2006a). Treatment for children with trauma-attachment disorders: Dyadic Developmental Psychotherapy. Child & Adolescent Social Work Journal, 23-#2, 147-171.
Becker-Weidman, A. (2006 b). Dyadic Developmental Psychotherapy: A multi-year Follow-up. In S. Sturt (Ed.). New developments In child abuse research, (pp. 43-60), NY: Nova Science Publishers.
The second study also found that four years after treatment, the group receiving DDP continued to have scores in the normal range (had achieved clinically and statistically significant positive change), but also that the comparison group, which was identical with the treatment group, showed several statistically significant increases in problem behaviors on the Achenback (Child Behavior Checklist).
I hope you find this helpful.
March 3rd, 2008 at 6:48 am
I see that Arthur B-W claims “a few empirical studies” supporting
DDP. In actuality, there is one such study, dating back to a time
when the intervention may not have been strictly DDP as it is
described here, and there is a follow-up report. A number of
confounding variables and statistical errors in this research make
it difficult to conclude that the treatment is effective. This has
been discussed in detail by Pignotti, M., & Mercer, J. (2007),
“Holding Therapy and Dyadic Developmental Psychotherapy are not
supported, acceptable social work interventions: A systematic
research synthesis revisited.” Research on Social Work Practice,
Vol. 17 (4), and by Mercer, J., & Pignotti, M. (in press, 2008),
“Shortcuts cause errors in systematic research syntheses: Rethinking
evaluation of mental health interventions.” Scientific Review of
Mental Health Practice.
March 4th, 2008 at 1:42 am
I very much enjoyed this article but was concerned about the tendency of therapists to re-invent the wheel by presenting ‘old wine in new bottles’. I couldn’t find anything in this article that makes this approach different from other forms of ‘attachment-based’ psychotherapy.
Regards,
Matthew
March 5th, 2008 at 9:06 am
Dear Matthew,
Thank you for the comment. The article is a very cursory summary of the approach. It is distinct from other forms of “attachment-based psychotherapy,” in several respects. There are several things you might want to look at to get further details. You might want to being with these two empirical studies in two professional peer reviewed publications that demonstrate the effectiveness of this approach:
Becker-Weidman, A., (2006a). Treatment for children with trauma-attachment disorders: Dyadic Developmental Psychotherapy. Child & Adolescent Social Work Journal, 13-1.
Becker-Weidman, A. (2006 b). Dyadic Developmental Psychotherapy: A multi-year Follow-up. In S. Sturt (Ed.). New developments In child abuse research, NY: Nova Science Publishers.
In addition, if you want further details, including a transcript of a session, you can look at:
Creating Capacity for Attachment, edited by Arthur Becker-Weidman and Deborah Sehll, (2005), Wood N Barnes, Oklahoma City, OK.
and Attachment focused Family Therapy by Daniel Hughes, (2007).
Two important distinctions are, when compared with the Circle of Security Program or PICT, is that this approach can be used with latency age children and families with teenagers, while those other two approaches are primarily for infants and toddlers. In addition, the emphasis on the intersubjective sharing of experience and the affective/reflective dialogue is another distinction with, for example, trauma-focused CBT.
regards
March 7th, 2008 at 6:26 pm
Jesse and Matthew,
Another very well done study produced by a group of independent researchers at a leading University (a quite prestigious group I might add) found that Dyadic developmental psychotherapy is an evidence-based treatment (classed as an acceptable and supported social work intervention under the criteria suggested by Saunders, Berliner, & Hanson (2004) (Craven & Lee, (2006), “Therapeutic Interventions for Foster Children: A systematic Research Synthesis,” Research on Social Work Practice, Vol. 16, #3, May 2006, pp. 287-304). You might want to take a look at this one too. I think their material also responds to your question, Matt.
March 14th, 2008 at 12:10 pm
a) Craven & Lee was a review of existing studies, not research.
b) they do not describe DDP as “evidence-based” but categorise it under Category 3, “supported and acceptable”. To be considered “evidence-based” you would usually need randomised controlled trials and to be accepted by the wider psychological community as “evidence based”.
c)Craven and Lee also placed holding therapy, from Myeroffs study, in Category 3, despite the fact that the original Saunders, Berliner & Hanson review placed attachment (including holding) therapy in Category 6: “concerning treatment”
d)The Craven & Lee study has been subsequently criticised in peer reviewed publications as cited above.
March 18th, 2008 at 4:16 pm
Dear Mat & Jessee,
One last point. When you read Craven & Lee, who are independent researchers at a leading University (a quite prestigious group I might add), they found that Dyadic developmental psychotherapy is an evidence-based treatment (classed as an acceptable and supported social work intervention under the criteria suggested by Saunders, Berliner, & Hanson (2004) (Craven & Lee, (2006), “Therapeutic Interventions for Foster Children: A systematic Research Synthesis,” Research on Social Work Practice, Vol. 16, #3, May 2006, pp. 287-304). You might want to take a look at this one too. I think their material also responds to your question, Matt.
What is most impressive, is that their review as based on a partial and preliminary presentation of data from an empirical outcome study (before the two studies that were published in professional peer-reviewed publications were out). Using their criteria, if they’d had the two empirical outcome studies from professional peer reviewed pubs, DDP would have been rated even higher.
The two empirical studies found that children who received DDP treatment showed clinical and statistically significant reductions in problem behaviors as measured by the Child Behavior Checklist. While, children who received “usual care” not only did not improve, they actually showed statistically significant deteriorations in behavior four years after treatment ended! There are also two other papers in press extending these discussions and results.
Thanks for you comments and ideas.
April 28th, 2008 at 11:11 am
I am very curious about this type of therapeutic approach. . . are you saying that adults and therapists will interact much the same way that parents will with young children in order to recreate those feelings of safety and security and that much of this will be via non verbal interaction? I am not sure that I could play either role in this therapy style. I think that most people would want to be much more verbal than what this would afford.
April 28th, 2008 at 11:11 am
Yeah I am a little confused about this too. I can see this maybe having a positive effect with children but I am a little more wary of how this would proceed with an adult patient.
April 29th, 2008 at 3:43 am
Dear Steve and Margo,
This article is just meant to be a brief summary, primarily for families, about this evidence-based treatment for children with complex trauma and disorders of attachment, such as found in foster and adoptive families, among others.
The basic idea is that trauma results in impairment in a number of domains and so treatment has to be directed toward those domains. One “active ingredient” of treatment is the intersubjective sharing of experience (see Fonagy regarding the reflective function and (Trevarthen, 2001; Stern, 1985) among others). This is shared emotion, intention, and attention. Merely having a pure verbal conversation will not produce therapeutic results for those who have experienced trauma (See Briere, 2006, for example). There has to be an emotional component to the dialogue, an affective/reflective dialogue to be precise, along with shared intention and shared attention. Maybe I should write an article here on intersubjectivity?
regards
May 1st, 2008 at 4:49 pm
In order for this therapy to be effective with birth parents of a four year old, is it essential to eradicate the bond formed with foster parents?
May 2nd, 2008 at 3:29 pm
Dear Nancy,
If a child has a disorder of attachment, then treatment that facilitates the development of a more healthy and secure attachment, such as with a foster parent, would be valuable. Once the child has developed the capacity to form an attachment, that capacity can be transfered to other relationships. So, if the child has now developed a healthy and secure attachment with a foster parent you would not want to “eradicate” that “bond.” It can be transfered to the new family…assuming that they are able to also facilitate that relationship. For example, if the birth parents’ own trauma has not been resolved, then that may likely interfere with the child’s forming a healthy and secure attachment with them…
regards
May 3rd, 2008 at 5:52 am
Although I’m aware that many people would ask the kind of question Nancy has asked, I think some further reading about attachment theory would help Nancy and others clarify their thinking about this. If we look at attachment from Bowlby’s viewpoint, we see that in a four-year-old attachment involves a set of feelings. thoughts, and expectations about social relations, and these are beginning to come together into an internal working model concerned with the ways people act toward each other. The idea of an “attachment” or a “bond” is metaphorical. There is nothing there to “break”, but instead a set of connected memories and emotions that need to be modified by new experiences so the child’s ways of being with other people are healthier and more constructive with respect to his or her present life. Treatments that work to modify the child’s internal working model can be effective, but those that are based on the metaphors of “breaking” and “binding” are potentially dangerous.
May 4th, 2008 at 11:23 am
Nancy,
Another factor to consider, is the history of the birth family. As I mentioned, if their own trauma is unresolved, that will require treatment and resolution before working with the family and child. In this regard, the evidence-based treatment model of Dyadic Developmental Psychotherapy can be quite helpful. Since the “best predictor” (Mary Main) of a child’s pattern of attachment is that of the caregiver, helping the caregiver develop a more healthy and secure pattern of attachment will benefit the child. If someone is suggesting that the “bond” with the foster parents be eliminated, I’d suggest getting another opinion. That advice does not sound consistent with any reputable approach of which I am aware.
Feel free to call me or contact me if you’d like to discuss this in more detail. My profile here has the contact information.
May 4th, 2008 at 2:57 pm
Regarding further reading, I’d recommend that if you wish to read more about attachment theory and treatment and about evidence based treatment, that you take a look at
Creating Capacity for Attachment, Edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, Wood N Barnes, Oklahoma City, OK, 2005. It has a good summary of attachment theory and about the evidence based treatment, Dyadic Developmental Psychotherapy, described in this article.