Arthur Becker-Weidman

Dyadic Developmental Psychotherapy: An evidence-baesd treatment

Part IV: detailed description of treatment

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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.

  1. 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.

  1. Sharing of subjective experiences.

  1. Use of PACE and PLACE are essential to healing.

  1. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

  1. Caregivers use attachment-facilitating interventions.

  1. 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.

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April 30, 2009 - Posted by | Arthur Becker-Weidman, Child Abuse, Child Welfare, Empirically supported, Evidence-based, Special Education, Treatment | , , , , , , , , , , , , ,

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