Exploring Dyadic Developmental Psychotherapy

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Exploring Dyadic Developmental Psychotherapy

• Attachment focused therapy for children
  experiencing difficulties feeling secure with
  caregivers
• Kim S. Golding

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Attachment Experience and The Life Path

• Attachment focussed therapies are an exploration
  of early experience on the life path.
• We are not pre-determined by early experience,
  but an outcome of long-term cumulative
  development of genetic/environmental interactions
  and transactions.
• Early experience impacts on how we process
  experience, makes some consequences more likely,
  environmental continuities. If reinforced effects
  of early experience will be strengthened.
• Therefore can get locked-in to life paths, (see
  Clarke Clarke, 2000).
• Attachment focussed therapies aim to prevent
  these locked-in life paths.

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The Life Path as a Tree

• At conception large range of pathways we might
  travel on.
• Chosen path interaction between child and
  environment.
• Change can shift child onto different pathway.
• Over time number of available pathways diminish.
• Therapy can help child move on to a more positive
  pathway.
• (See Bowlby, 1988/1998).

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Attachment-focused Therapies

• Aim to guide the child or young person onto a
  more favourable developmental pathway by
• Enhancing their experience of intersubjectivity
  through a more secure attachment.
• Using this to
• Recover from developmental trauma.
• Overcome shame-based difficulties.

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Attachment-focused Therapies

• So that the child is more able to
• Trust relationships (reduce excessive
  help-seeking and dependency or reduce social
  isolation and disengagement).
• Manage stress (able to focus attention and
  control arousal).
• Regulate emotion and develop reflective skills.

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Evidence Base

• Clinical Study of foster or adoptive children
  (Becker-Weidmann, 2006a, b).
• Treatment group (DDP) N34, comparison group
  (intervention as usual) N30.
• Onset of intervention no significant difference
  between groups (Child behaviour checklist, CBCL).
• One year post treatment DDP group demonstrated
  significant improvements on 7 categories of CBCL
  whilst comparison group demonstrated no
  improvements.
• Four years post treatment these improvements
  maintained for DDP group, whilst comparison group
  had worsened or stayed the same.

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Theoretical Base

• With a limited evidence base it is important for
  ethical practice that the intervention is
  robustly based upon theoretical principles.
• Three theoretical areas are very relevant
• Attachment Theory.
• Intersubjectivity.
• Trauma.

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Theoretical Principles Attachment Theory
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• Psychotherapy based on attachment theory and
  research actively facilitates the experience of
  safety that is necessary if the child is to
  remain engaged in exploring and resolving
  experiences of terror and shame.
• (Dan Hughes, 2004).

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• I am using attachment to mean a pattern of
  behaviour which is care-seeking and
  care-eliciting from an individual who feels they
  are less capable of dealing with the world than
  the person to whom they are seeking care.
  (Bowlby, 1988/1998).
• Development of relationships in order to feel
  safe.
• Feeling safe is foundation for child development
  allowing exploration and learning involving
  integrated brain functioning.
• Security of attachment leads to an expanded
  range of exploration. Fear constricts, safety
  expands the range of exploration. (Fosha, 2003).

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Bowlbys Model for Intervention

• Provide a secure base, facilitating exploration.
• Provide support, encouragement, sympathy
  guidance enhance developmental pathway.
• Facilitate development of healthy relationships.
• Facilitate positive expectations of attachment
  figure.
• Understand past consider ideas and feelings
  about parents that have been unimaginable and
  unthinkable.
• By these means the therapist hopes to enable
  his patient to cease being a slave to old and
  unconscious stereotypes and to feel, to think,
  and to act in new ways. (Bowlby, 1988/1998).

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The Therapist

• Encourage exploration of thoughts, feelings
  actions.
• Be empathic, reliable, attentive, sympathetic and
  sensitively responsive.
• See and feel the world through the others eyes.
• Offer acceptance and respect of other.
• View current behaviour beliefs as the not
  unreasonable products of what has been told or
  experienced in the past.
• Focus on interactions in here and now. Explore
  past to throw light on current feelings
  behaviour.
• Provide the conditions in which self-healing can
  take place.

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Barriers To Change

• Lack of trust because of past experience leads
  to
• Anxiety, distrust, criticism, anger and contempt
  fighting old battles.
• Or.
• Attention and sympathy leads to unrealistic
  expectation of all the care and affection that
  has been yearned for but not received in past.
• Whenever a therapist is puzzled by, or
  resentful of, the way he is being treated by a
  patient, he is always wise to enquire when and
  from whom the patient may have learned that way
  of treating other people. More often than not it
  is from one of his parents.
• (Bowlby, 1988/1998).

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Those who cannot remember the past are condemned
to repeat it. Santayana. The Life of
Reason, vol1, Scribner 1905
When you feel you know the future you can be
sure that your are reliving the past.because
nobody knows the future. (Annie Rogers, A
Shining Affliction,Penguin, 1993)
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Theoretical Principles Intersubjectivity
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• Intersubjectivity.
• Joint attention learn to regulate attention,
  when lacking risk of attentional difficulties
  (ADHD/ADD).
• Joint affect learn to regulate emotion, when
  lacking increases risk of mood disorders
  (anxiety/depression) and risk of difficulties
  with dissociation and dysregulation.
• Joint intention learn to engage in
  co-operative behaviour, when lacking increases
  risk of oppositional behaviour (ODD).

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• When the infant and young child begins to
  explore her world, her first interest is the
  interpersonal world. A central characteristic of
  such exploration optimised in circumstances of
  attachment security involves primary and
  secondary intersubjectivity.
• (Dan Hughes, 2006).

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Primary Intersubjectivity

• Infant and parent discover each other in a
  reciprocal relationship.
• In the process discover more about themselves.
• The child develops a sense of self, reflected in
  the response to her from the parents.
• (See Trevarthen, 2001).

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Secondary Intersubjectivity

• Child learns about world of people, events and
  objects.
• Child and parent together focus attention
  outwards. Shared attention helps them to explore
  the world and learn about the impact on each
  other.
• Child learns about the world though the meaning
  parent gives. Helps child develop the capacity to
  think.
• The world, self and others makes sense.
• Child learns to reflect upon, process and learn
  from experience.
• (See Trevarthen, 2001).

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• Children who experience neglect lack early
  intersubjective experience. They feel not special
  and not loveable.
• Children who experience anger, fear or rejection
  experience terror and shame. They learn to avoid
  intersubjective experience.
• Living with alternative parents child continues
  to avoid intersubjective experience.
• This impacts on carers beliefs about self as a
  parent leading to a sense of failure, feel unsafe
  with child.
• Carer also withdraws from intersubjective
  experience.

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Therapy

• The focus of therapy is to help both child and
  parent feel safe enough to enter into an
  intersubjective experience.
• More than anything else, the child needs his
  parent to assist him in discovering who he is and
  who he can become.
• (Dan Hughes, 2006).

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Theoretical PrinciplesTrauma
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Developmental or Complex Trauma

• The majority of children referred for an
  attachment-focussed intervention will have been
  exposed to multiple traumatic events impacting on
  immediate and long-term outcomes (complex trauma,
  see Briere Scott, 2006).
• This is also described as developmental trauma,
  defined as exposure to multiple or chronic
  interpersonal trauma, with early onset, impacting
  upon development. (See Cook et al, 2005 van der
  Kolk, 2005).

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Neurosequential Model

• Based on neurodevelopmental principles
• The brain is organized hierarchically, sensory
  input first enters the lower parts of the brain.
• Brain development occurs in a use-dependent
  fashion.
• The brain develops sequentially.
• The brain develops most rapidly early in life.
• Neural systems can be changed, some more easily
  than others.
• The human brain is designed for a different
  world.
• (See Perry, 2006).

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Self-Trauma Model

• Emotional processing occurs when exposed to
  trauma-reminiscent stimuli
• Triggers associated implicit and/or explicit
  memories.
• Activates emotional and cognitive responses
  hooked to these memories.
• But responses not reinforced by current
  environment.
• Or counterconditioned by opposite emotional
  experience.
• Leading to extinction of original
  memory-emotion/cognition association.
• (Briere Scott, 2006).

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Self-Trauma Model

• This model predicts that traumatized individuals
  will re-experience traumatic events (eg via
  flashbacks, re-enactments) in conditions of
  safety as part of self-healing.
• But the experience is titrated through effortful
  avoidance so that it is not overwhelming.

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Intervention principles derived from trauma
literature

• Children need to experience safety and
  relationships that are different from original
  relationships.
• Children need opportunities for new experiences
  than can over time reduce the associations that
  have been built around the trauma.
• These corrective experiences need to be
  consistent, predictable, patterned and frequent.

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Intervention principles derived from trauma
literature

• Interventions need to take into account where the
  child is on the arousal continuum may need to
  help children to be physiologically regulated.
• Help children to develop improved affect
  regulation abilities.
• Provide titrated exposure to traumatic memories.
• Provide emotional and cognitive processing
  leading to development of coherent narrative.

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DYADIC DEVELOPMENTAL PSYCHOTHERAPYClinical
Principles
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Dyadic Developmental Psychotherapy (Dan Hughes)

• Therapist and carer work together with the child.
• Playful, Accepting, Curious, Empathic.
• Creates an environment that facilitates healthy
  relationship development.
• Offers increased sensitivity, availability and
  responsiveness.
• Co-regulates emotion and co-constructs meaning.
• Builds trust.
• Facilitates intersubjective experience and secure
  attachment.
• Contains anxiety and supports exploration.

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The Therapist

• Is directive determines pace, themes,
  activities, and techniques modified by ongoing
  attunement with the childs responses to the
  interventions.
• Provides recurring sequences of attachment
  affective union, separation and reunion
  experiences for the child, thus facilitating
  intersubjective experience between parent and
  child.

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The Therapist

• Maintains and models The Attitude
• Playful.
• Acceptance.
• Curious.
• Empathic.

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The Therapist

• Focus on experience related to themes of
  attachment, abuse and neglect.
• Dependency, comforting, affection, reciprocal
  enjoyment.
• Ambivalence associated with attachment emotions
  and behaviours.
• Fear of abandonment, rejection, isolation, abuse.
• Sense of being worthless and bad.
• Despair over being unwanted, unloved.
• Shame/rage associated with above emotional
  experiences.

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The Therapist and Carer

• Relationship-centred. Therapist facilitates
  relationship between child and carer.
• Therapist and carer continually communicate
  emotionally with the child.
• Help child to be more aware of inner life of
  thought, affect, wishes and intentions as well as
  traumatic memories.

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The Carer

• Present and actively involved.
• Provides affective attunement.
• Enters into intersubjective experience with
  child.
• Experiences mutual enjoyment with child.
• Demonstrates differences from abusing adults.
• Participates in developing joint plans and
  strategies for therapy.
• May need to explore own attachment history.

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Techniques

• Orchestrate parent-child emotional communication
• Speak for child to parent/to therapist/to
  abusive-neglecting parent.
• Direct child to express emotional experience to
  parent, in therapists words/in own words.
• Encourage parent to engage in reciprocal
  emotional communication.
• Help child to tolerate comfort to support
  expression of shame, rage, fear, sadness.

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Techniques

• Use variety of therapeutic approaches to support
  the therapy. For example
• Psychodrama.
• Narratives.
• Puppets, soft toys, books.
• Visualizations.
• Massage, movement, music, food.
• Relationship based play.

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PACE

• An attitude that the therapist and parent hold,
  which will help them to maintain emotional
  engagement with the child.
• Stay curious (C)about why less likely to feel
  cross or frustrated. Non-judgemental and
  therefore help child to be open to
  intersubjective experience of self, others and
  events.

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PACE

• Curiosity leads to understanding, which increases
  acceptance (A) of child, his internal experience
  and reasons for his behaviour. Creates
  psychological safety.
• Provide the child with empathy (E) and support.
  Child experiences therapist and parents as with
  him as he explores past and current experience.

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PACE

• A playful (P) stance can diffuse a situation and
  help the child to stay with the intersubjective
  experience.
• Intersubjectivity is primarily a here-and-now,
  you-and-me experience in which both are sharing
  joint attention as well as similar affect,
  intention and meaning.
• (Dan Hughes, 2004).

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Co-regulation of Emotion

• Development of affective abilities.
• Childs affective response to the experience is
  being co-regulated by the therapists affective
  response.
• As the therapist responds to the childs
  affective states, nonverbally and verbally, they
  mark the affect with an empathic, congruent
  response.
• This helps the child to create a secondary
  representation of the original affect and leads
  to the capacity for reflective thought (see
  Fonagy et al 2002).

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Co-construction of Meaning

• Development of reflective abilities.
• The childs attention is being held by the
  therapists attentive stance.
• The therapist also provides words so that the
  child can gradually identify and more fully
  express his inner life.
• Through the intersubjective process the child is
  able to co-construct the meaning of his
  experience.
• He integrates the meanings given to the
  experience through the interwoven perspectives of
  therapist, parent and self.

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Parenting to Support DDP
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Parenting to Support DDP

• Attachment state of mind of carer is important
  for ultimate security of foster child.
• Carers with autonomous state of mind more likely
  to care for children demonstrating secure
  behaviour.
• Therefore parents attachment history is an
  important component of DDP.
• A carer will avoid intersubjective connection
  with her child if this leads to beliefs that she
  is failing as a parent and/or if it activates
  unresolved experiences from her attachment
  history.
• Carers need to be able to reflect upon their
  experience and to have resolved difficult
  experience make sense of experience, the impact
  on them and have reached acceptance of this.

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Understanding and Managing Shame

• DDP actively facilitates the experience of
  safety necessary for child to remain engaged in
  exploring and resolving experiences of shame.

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Understanding and Managing Shame

• Shame is an affect, a complex emotion that
  develops later than the development of more
  straightforward feelings or emotions such as
  anger, joy or sadness.
• Shame is uncomfortable for children who learn to
  limit shame-inducing behaviours as part of the
  socialisation process.
• Shame is protective, it helps children to learn
  socially acceptable behaviour and thus to be able
  to develop relationships.
• This experience of shame is integrative.

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Child behaves inappropriatelyEg pulls dog by
tail.
Parent provides boundaryYou mustnt hurt the
dog.
Child notices effects of behaviour on
others. Feels GUILT for hurting
another. Development of EMPATHY
Child experiences SHAMEGoes quiet, looks away,
makes self smaller, hides self.
Parent reassures childIts not you, this is
about behaviour.Its not our relationship, I
am teaching you appropriate behaviour.
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Shame and Guilt

• Parent supports child and shame reduces.
• Child experiences feelings of guilt, but this is
  about my behaviour not me.
• Child looks outward How does the other person
  feel?
• Child accepts responsibility and feels sorry.
• Motivated to make amends.
• Freedom to learn from mistakes.

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When Shame grows big

• Child is unsupported, shame gets bigger.
• Child experiences feelings about self, looks
  inward. I am bad, worthless, stupid.
• Denies shame, stops feeling it. Cannot think
  about other person, accept responsibility or feel
  sorry.
• Does not develop feelings of guilt, not able to
  make amends. Does not develop empathy.
• Child defends against these feelings of shame
  lies, blames, minimizes and rages. May
  internalise the feelings through
  self-chastisement and self-harming behaviours.

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When Shame is Disintegrative

• Children do not experience attunement-shame-re-att
  unement cycle but instead they experience
  unregulated shame that overwhelms them.
• Many experiences of disintegrative shame leads to
  shame becoming part of core-identity. I am a
  shameful person, leads to chronic anger and
  controlling behaviours.
• Children need appropriately graded doses of shame
  and support and reassurance to help them manage
  this, or the shame engulfs them.
• Children feel alienated and defeated, never quite
  good enough to belong. Trapped in shame,
  abandoned. Shame becomes toxic.
• Children experience difficulty regulating emotion
  and thinking rationally. Unable to respond
  flexibly or to control impulses.

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Shame and Guilt in DDP

• Shame is differentiated from guilt, although in
  some theoretical perspectives these terms are
  used interchangeably (eg Kaufman. 1996).
• Healthy guilt is seen as following on from shame
  in the development of conscience, resulting in
  social learning and appropriate remorse.
• Feelings of guilt, triggered by shame, leads us
  to regret and sorrow for our poor choices,
  informing our core beliefs and values.

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Shame and Guilt in DDP

• A core aim of DDP is to enable children to move
  from overwhelming shame and associated negative
  self-evaluations (I am bad, you will not love
  me) into healthy guilt.
• Children can then view misdemeanours as events
  which can be learnt from, rather than as
  disastrous and irreparable.
• Healthy guilt and remorse is an ordinary feature
  of relationships which sustain and provide
  ongoing love and care.
• It is this understanding which DDP aims to convey
  to children.

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The Therapist

• Pervasive shame is a barrier to engaging in
  therapeutic process.
• Therapist uses empathy and curiosity, accepting
  childs resistance and helping him to stay
  engaged.
• As therapist accepts and is curious about the
  child without being judgemental, including shame
  of his past, a new non-shame based meaning is
  co-constructed.
• When the child dysregulates the therapist remains
  regulated, using acceptance and empathy to
  co-regulate the intense affect, and to
  co-construct new meaning, reducing the shame of
  this experience.

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The Carer

• Fear triggers attachment behaviours, but shame
  will inhibit this.
• The therapy works with the carer to help child
  stop hiding from attachment figure and to begin
  to trust and elicit care from her.
• The child experiences the carers empathy,
  curiosity, acceptance and playfulness about the
  full range of experiences explored.
• This helps the child to take the shame-reducing
  therapeutic experience into his daily life.

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References

• Becker-Weidman, A. (2006a). Treatment for
  children with trauma-attachment disorders Dyadic
  Developmental Psychotherapy. Child and Adolescent
  Social Work Journal, March, 2006.
• Becker-Weidman, A. (2006b). Dyadic Developmental
  Psychotherapy a multi-year follow-up. In New
  Developments in Child Abuse Research. S.M.
  Sturt, Ed. Nova Science Publishers.
• Bowlby J (1988/1998) A secure base. Clinical
  applications of attachment theory.
  LondonRoutledge.
• Briere, J, N. Scott C. (2006) Principles of
  trauma therapy A guide to symptoms, evaluation
  and treatment. Sage Publications.

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References

• Clarke A Clarke A (2000) Early Experience and
  The Life Path. JKP.
• Cook, A Spinazzola, J. et al (2005) Complex
  trauma in children and adolescents. Psychiatric
  Annals, 35, 390 395.
• Fonagy PGergely G Jurist E.L Target M (2002)
  Affect regulation,mentalization, and the
  development of the self. NY Other Press.
• Fosha, D. (2003) Dyadic regulation and
  experiential work with emotion and relatedness in
  trauma and disorganized attachment. In Soloman
  Siegel Chapter 6. p221-281.

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References

• Golding, K. S. (2008) Nurturing Attachments.
  Supporting children who are fostered or adopted.
  London Jessica Kingsley Publishers.
• Hughes D. A. (2004) An attachment-based treatment
  of maltreated children and young people.
  Attachment Human Development, 6,3, 263-278.
• Hughes D.A (2006) Building the bonds of
  attachment. Awakening love in deeply troubled
  children. Aronson,.2nd Edition.
• Hughes D. A. (2007) Attachment-Focused Family
  Therapy. W.W. Norton Co. Ltd.
• Kaufman G (1996) The Psychology of Shame. Theory
  and treatment of shame-based syndromes. NY
  SpringerPublCo. 2nded. (1sted 1989).

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References

• Perry, B. D. (2006) Applying principles of
  neurodevelopment to clinical work with maltreated
  and traumatized children. The neurosequential
  model of therapeutics. In Webb, N. B. (ed)
  Working with traumatized youth in child welfare.
  Chapter 3, Pp 27-52. NY The Guilford Press.
• Trevarthen, C. (2001) Intrinsic motives for
  companionship in understanding their origin,
  development, and significance for infant mental
  health. Infant Mental health journal, 22,
  95-131.
• van der Kolk (2005) Developmental trauma
  disorder. Towards a rational diagnosis for
  children with complex trauma histories.
  Psychiatric Annals, 5, 401 408.