Exploring Dyadic Developmental Psychotherapy - PowerPoint PPT Presentation

Loading...

PPT – Exploring Dyadic Developmental Psychotherapy PowerPoint presentation | free to view - id: 481930-Nzk3N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Exploring Dyadic Developmental Psychotherapy

Description:

Exploring Dyadic Developmental Psychotherapy Attachment focused therapy for children experiencing difficulties feeling secure with caregivers Kim S. Golding – PowerPoint PPT presentation

Number of Views:319
Avg rating:3.0/5.0
Slides: 67
Provided by: gold91
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Exploring Dyadic Developmental Psychotherapy


1
Exploring Dyadic Developmental Psychotherapy
  • Attachment focused therapy for children
    experiencing difficulties feeling secure with
    caregivers
  • Kim S. Golding

2
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.

3
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).

4
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.

5
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.

6
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.

7
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.

8
Theoretical Principles Attachment Theory
9
  • 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).

10
  • 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).

11
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).

12
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.

13
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).

14
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)
15
Theoretical Principles Intersubjectivity
16
  • 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).

17
  • 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).

18
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).

19
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).

20
(No Transcript)
21
  • 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.

22
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).

23
Theoretical Principles Trauma
24
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).

25
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).

26
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).

27
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.

28
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.

29
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.

30
DYADIC DEVELOPMENTAL PSYCHOTHERAPY Clinical
Principles
31
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.

32
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.

33
The Therapist
  • Maintains and models The Attitude
  • Playful.
  • Acceptance.
  • Curious.
  • Empathic.

34
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.

35
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.

36
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.

37
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.

38
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.

39
(No Transcript)
40
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.

41
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.

42
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).

43
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).

44
(No Transcript)
45
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.

46
(No Transcript)
47
Parenting to Support DDP
48
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.

49
(No Transcript)
50
Understanding and Managing Shame
  • DDP actively facilitates the experience of
    safety necessary for child to remain engaged in
    exploring and resolving experiences of shame.

51
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.

52
(No Transcript)
53
Child behaves inappropriately Eg pulls dog by
tail.
Parent provides boundary You mustnt hurt the
dog.
Child notices effects of behaviour on
others. Feels GUILT for hurting
another. Development of EMPATHY
Child experiences SHAME Goes quiet, looks away,
makes self smaller, hides self.
Parent reassures child Its not you, this is
about behaviour. Its not our relationship, I
am teaching you appropriate behaviour.
54
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.

55
(No Transcript)
56
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.

57
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.

58
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.

59
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.

60
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.

61
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.

62
(No Transcript)
63
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.

64
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.

65
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).

66
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.
About PowerShow.com