University of Cambridge

Dyadic Developmental Psychotherapy: an Evidence-based Treatment for Disorders of Attachment; the Empirical Support

Dyadic Developmental Psychotherapy (DDP) is an evidence-based and effective form of treatment for children with trauma and disorders of attachment[1]. It is an evidence-based treatment, meaning that there has been empirical research published in peer-reviewed journals. Craven & Lee (2006) determined that DDP is a supported and acceptable treatment (category 3 in a six level system). However, their review only included results from a partial preliminary presentation of an ongoing follow-up study, which was subsequently completed and published in 2006. This initial study compared the results of Dyadic Developmental Psychotherapy with other forms of treatment, ‘usual care’, 1 year after treatment ended. It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment mean a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in Dyadic Developmental Psychotherapy being classified as an evidence-based category 2, ‘Supported and probably efficacious’. There have been two related empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

* 1. The treatment has a sound theoretical basis in generally accepted psychological principles.

Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below

* 2. A substantial clinical, anecdotal literature exists indicating the treatment’s efficacy with at-risk children and foster children.

See reference list.

* 3. The treatment is generally accepted in clinical practice for at risk children and foster children.

As demonstrated by the large number of practitioners of Dyadic Developmental Psychotherapy and it’s presentation as numerous international and national conferences over the last ten or fifteen years.

* 4. There is no clinical or empirical evidence or theoretical basis indicating – that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

* 5. The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation.

Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.

* 6. At least two studies utilizing some form of control without randomization (e.g., wait list, untreated group, placebo group) have established the treatment’s efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already established treatment.

See ref. list

* 7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supported the efficacy of the treatment.

These studies support several of O’Connor & Zeanah’s[2] conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.”

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment[3].

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first few years of life. These experiences disrupt the normal attachment process so that the child’s capacity to form a healthy and secure attachment with a caregiver is distorted or absent. The child lacks a sense trust, safety, and security. The child develops a negative working model of the world in which:

Ø Adults are experienced as inconsistent or hurtful.

Ø The world is viewed as chaotic.

Ø The child experiences no effective influence on the world.

Ø The child attempts to rely only on him/her self.

Ø The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems and even Psychotic Disorder symptoms are often seen in children with disorganized attachment[4].

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms[5]. Many of these children are violent[6] and aggressive[7] and as adults are at risk of developing a variety of psychological problems[8] and personality disorders, including antisocial personality disorder[9], narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder[10]. Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence[11]. Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults[12]. Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average)[13] (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults[14].

FIRST PRINCIPAL. Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are one “active ingredient” in the healing process.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way (More details of this story can be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My first therapy was with Dr.Steve. The therapy was FUN!!!! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn’t know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me

I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can’t overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn’t take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn’t because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn’t get hurt anymore. But the bricks kept the love out too. I wouldn’t let Mom’s love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom’s love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don’t need therapy. I still let Mom’s love into my heart!!!!!! Sometimes I send e-mail’s to Dr. Art. I tell him how good I’m doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom “I don’t need therapy. I just want to have lunch with Dr. Art.” So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it’s still hard. I still get mad and sometimes I don’t express my feelings well. Sometimes when Mom helps me ? I can express my feelings and say “I don’t want to pick up my toys. It makes me mad that I have to ? but I will”. When I say that it doesn’t make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It’s been a really longtime since I tried to hurt Mom or break things when I’m mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don’t feel like I’m a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement within the family. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy must be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in “titrated” and manageable doses so that what the parents have to offer can get in and heal the child. It is the parents’ capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the “attitude[15]” that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child’s trauma. Revisiting the trauma is essential if the child is to begin to revise the child’s personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. “Compression-wraps,” invasive and intrusive stimulation designed to evoke rage, “re-birthing,” and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not used in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children’s White Paper on Coercion in treatment.

DETAILED DESCRIPTION OF TREATMENT

Dyadic Developmental Psychotherapy is a treatment developed by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:

  1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.
  2. 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.
  3. Sharing of subjective experiences.
  4. Use of PACE and PLACE are essential to healing.
  5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.
  6. Caregivers use attachment-facilitating interventions.
  7. Use of a variety of interventions, including cognitive-behavioral strategies.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the necessity for sensitive care-giving. As O’Connor & Zeanah (2003, p. 235) have stated, “A more puzzling case is that of an adoptive/foster caregiver who is ‘adequately’ sensitive but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in already sensitive parent) would yield positive changes in the parent-child relationship.” Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another part of the foundation on which Dyadic Developmental Psychotherapy rests.

The primary approach is to create a secure base in treatment (using techniques that fit with maintaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principals that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned relationship within which contingent collaborative communication occurs helps the child heal. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an emotional response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never used and are inconsistent with a treatment rooted in attachment theory and current knowledge about the neurobiology of interpersonal behavior.

The usual structure of a session involves three components. First, the therapist meets with the caregivers in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman & Shell (2005) Hughes, 2006). The caregiver’s own issues that may create difficulties with developing affective attunement with their child may also be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this part of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child. Second, the therapist with the caregivers meets with the child in the treatment room. This generally takes one to one and a half hours. Third, the therapist meets with the caregivers without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude.

Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children. Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma. This affective attunement is the same process used for non-verbal communication between a caregiver and child during attachment facilitating interactions (Hughes, 2003, Siegel, 2001). The therapist and caregivers’ attunement results in co-regulation of the child’s affect so that is it manageable. Cognitive restructuring interventions are designed to help the child develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative. Treatment involves multiple repetitions of the fundamental caregiver-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the relationship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are essential elements to creating affective attunement.

The treatment provided often adhered to a structure with several dimensions. It is pictured in Figure 1, below. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore and the meaning to the child begins to emerge. Third, empathy is used to reduce the child’s sense of shame and increase the child’s sense of being accepted and understood. Forth, the child’s behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn’t want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.

Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the behavior is found and the child’s actions are integrated into a coherent autobiographical narrative by communicating the new experience and meaning to the caregiver.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child’s behavioral disturbances. The child develops secondary representations of these events, feelings and thoughts that result in greater affect regulation and a more integrated autobiographical narrative.

As described by Hughes (2006, 2003), the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child’s emerging affective states and developing secondary representations of thoughts and feelings, the child’s capacity to affectively engage in a trusting relationship is enhanced. The caregivers enact these same principals. If the caregivers have difficulty engaging with their child in this manner, then treatment of the caregiver is indicated.

Children who have experienced chronic maltreatment and resulting complex trauma are at significant risk for a variety of other behavioral, neuropsychological, cognitive, emotional, interpersonal, and psychobiological disorders (Cook, A., et. al., 2005; van der Kolk, B., 2005). Children and adolescents with complex trauma require an approach to treatment that focuses on several dimensions of impairment (Cook, et. al., 2005). Chronic maltreatment and the resulting complex trauma cause impairment in a variety of vital domains including the following:

Ø Self-regulation

Ø Interpersonal relating including the capacity to trust and secure comfort

Ø Attachment

Ø Biology, resulting in somatization

Ø Affect regulation

Ø Increased use of defensive mechanisms, such as dissociation

Ø Behavioral control

Ø Cognitive functions, including the regulation of attention, interests, and other executive functions.

Ø Self-concept.

Dyadic Developmental Psychotherapy addresses these domains of impairment. Dyadic Developmental Psychotherapy shares many important elements with optimal, sound social casework and clinical practice. For example, attention to the dignity of the client, respect for the client’s experiences, and starting where the client is, are all time-honored principles of clinical practice and all are also central elements of Dyadic Developmental Psychotherapy

In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness.

[1] Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 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 — 61.

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

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.

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

[2] O’Connor, T., & Zeanah, C., (2003) Attachment Disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-245.

[3] Hughes, D., (2008) Attachment-focused Family Therapy. NY: Norton.

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

Solomon, J. & George, C. (Eds.). Attachment Disorganization. NY: Guilford Press, 1999.

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Carlson, E.A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128.

[5] 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.

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

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[8] Schreiber, R. & Lyddon, W. J. (1998) Parental bonding and Current Psychological Functioning Among Childhood Sexual Abuse Survivors. Journal of Counseling Psychology, 45, 358-362.

[9] 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.

[10] 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.

[11] 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.

[12] Allan, J. (2001). Traumatic Relationships and Serious Mental Disorders. NY: John Wiley.

Andrews, B., Varewin, C.R., Rose, S., & Kirk (2000). Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, 109, 69-73.

[13] MacMillian, H.L. (2001). Childhood Abuse and Lifetime Psychopathology in a Community Sample. American Journal of Psychiatry, 158, 1878-1883.

[14] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001.

Andrews, B., Varewin, C.R., Rose, S. & Kirk. Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, vol. 109, 69-73, 2000.

[15] Hughes, D., (2007) Building the Bonds of Attachment, 2nd. Edition, NY: Guilford Press.

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