Dyadic Developmental Psychotherapy

Dyadic Developmental Psychotherapy is a treatment approach for families that have children with symptoms of emotional disorders, including Complex Trauma and disorders of attachment.^[1] It was originally developed by psychologist Daniel Hughes as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers.^[2][3] Hughes cites attachment theory and particularly the work of John Bowlby as theoretical motivations for dyadic developmental psychotherapy.^[3][4][5] However, other sources for this approach may include the work of Stern,^[6] who referred to the attunement of parents to infants' communication of emotion and needs, and of Tronick,^[7] who discussed the process of communicative mismatch and repair, in which parent and infant make repeated efforts until communication is successful.

Dyadic developmental therapy principally involves creating a "playful, accepting, curious, and empathic" environment in which the therapist attunes to the child’s "subjective experiences" and reflects this back to the child by means of eye contact, facial expressions, gestures and movements, voice tone, timing and touch, "co-regulates" emotional affect and "co-constructs" an alternative autobiographical narrative with the child. Dyadic developmental psychotherapy also makes use of cognitive-behavioral strategies. The "dyad" referred to must eventually be the parent-child dyad. The active presence of the primary caregiver is preferred but not required.^[3]

Two studies by Arthur Becker-Weidman concluded that dyadic developmental therapy is more effective than the "usual treatment methods" for reactive attachment disorder and complex trauma.^[8][9] This conclusion has been criticised. According to the APSAC Taskforce Report and Reply, (Chaffin et al. 2006), dyadic developmental psychotherapy does not meet the criteria for designation as "evidence based" nor provide a basis for conclusions about "usual treatment methods". The approach has been described as a "supported and acceptable" treatment approach in a systematic research synthesis evaluating treatment for foster children, (Craven & Lee 2006)^[10][11][12] but this conclusion has also proved controversial. Becker-Weidman and Hughes state that dyadic developmental psychotherapy meets the standards for non-coerciveness of the American Professional Society on the Abuse of Children, The American Academy of Child Psychiatry, American Psychological Association, American Psychiatric Association, National Association of Social Workers, and various other groups concerned with treatment of children and adolescents. Daniel Hughes, described by the APSAC Taskforce as a 'leading attachment therapist' cites a list of attachment therapy techniques specifically forsworn by him on his website.^[13]

Theoretical basis

Dyadic developmental psychotherapy is based on the theory that maltreated infants not only frequently have disorganized attachments but also, as they mature, are likely to develop rigid self-reliance that becomes a compulsive need to control all aspects of their environment. Hughes cites Lyons-Ruth & Jacobvitz (1999) in support of this theory. Caregivers are seen as a source of fear with the result that children endeavour to control their caregivers through manipulation, overcompliance, intimidation or role reversal in order to keep themselves safe. Such children may also suffer intrusive memories secondary to trauma and as a result may be reluctant or unwilling to participate in treatment. It is anticipated that such children will try to actively avoid the exposure involved in developing a therapeutic relationship and will resist being directed into areas of shame and trauma. Hughes proposes that an attachment based treatment may be more effective for such foster and adoptive children than traditional treatment and parenting interventions.^[3]

It is stated that once an infant's safety needs are met (by attachment) they become more able to focus on learning and responding to the social and emotional needs of caregivers. (Schore, 2003ab). Hughes posits that this 'affective attunement', described by Stern (1985) is crucial in the development of both a secure attachment as well as a positive, integrated sense of self. Attunement is seen as primarily a non-verbal mode of communication between infant and carer, and synchrony in the degree of arousal being expressed, as well as empathy for the child's internal experience. Hughes states "Whether it is a motivational system separate from attachment as is suggested by Stern (2004), or a central aspect of a secure attachment dyad, it remains vital in the child’s overall development." Through this process, the children co-construct the meaning of their experience and co-regulate their affective response. This leads to the capacity for self awareness and eventually development of autonomy.^[3]

The therapy attempts to replicate this or fill in the gaps in a maltreated child's experience.

Methods

Firstly the therapist becomes 'non-verbally attuned' with the child’s affective state. The therapist then attempts to explore 'themes' with the child whilst remaining attuned. Whilst this is done, the therapist then 'co-regulates' (helps the child to manage) the child’s emerging affective states with 'matched vitality affect', and develops secondary affective/mental representations of them which is co-constructed with the child for purposes of integration (the therapist tries to help the child gain a coherent narrative about their experiences and an awareness of the positive aspects of themselves). According to Hughes "The therapist allows the subjective experience of the child to impact the therapist. The therapist can then truly enter into that experience and from there express her/his own subjective experience. As the therapist holds both subjective experiences, the child experiences both. As the child senses both, the child begins to integrate them and re-experience the event in a way that will facilitate its integration and resolution." Hughes (2004)^[3] In the anticipated frequent disruptions, due to the child’s traumatic and shaming experiences, the therapist accepts and works with these and then 'repairs' the relationship.

This 'nonverbal dance' should run through both positive and negative experiences. It is posited that maintaining/re-establishing attunement during negative affective experiences prevents the child from entering into a state of affective, behavioral, and cognitive disregulation (the child's feelings becoming out of control). The aim is for the therapist and child to develop a new common meaning for the traumatic experiences, shame-based behaviors, and the dyadic process itself (how you experience another, and how they experience you), and for the child to feel safe, understood and validated at a sensory-affective, pre-verbal level of experience.^[3]

According to Hughes, the primary inter-subjective stance is one of acceptance and curiosity, empathy, (love) and/or playfulness, (later reduced to the acronym PACE or PLACE), all the while committed to remaining emotionally engaged and available to the child. It is an active, affectively varied, dyadic interaction that interweaves moments of experience and reflection. According to Hughes it is non-coercive and is intended to lead to the child feeling better understood and having a better understanding of themselves.

According to Hughes, what he describes as the 'attachment sequence of attunement, disruption, and repair' occurs frequently in an attachment-based model of therapy, just as it does in the parent-child relationship. 'Resistance' is described as a disruption in the relationship that is then co-regulated by the therapist. This involves the therapist guessing how the child feels in order to be able to empathize and express the feeling. Curiosity and acceptance are considered crucial to this process. The therapist 'co-regulates' the child's dysregulated responses to 'co-construct' a new meaning.

The ultimate aim is for the child to be able to construct a new and coherent autobiography that enables the child to be in touch with their inner feelings. "As the therapist gives expression to the child’s subjective narrative, s/he is continuously integrating the child’s nonverbal responsiveness to the dialogue, modifying it spontaneously in a manner congruent with the child’s expressions. The dialogue is likely to have more emotional meaning for the child if the therapist, periodically, speaks for the child in the first person with the child’s own words." (Hughes 2004 p18)^[3]

Role of caregiver

The active presence of one of the child’s primary caregivers is considered to greatly enhance psychological treatment that involves establishing dyadic interactions of nonverbal attunement, affective/reflective dialogue and frequent repair as such participation by the caregiver makes it easier for children to incorporate these transforming experiences into their daily lives. It follows therefore that the affective/reflective capacities of the foster/adoptive caregiver—along with those of the therapist—must be adequately developed if children are to develop similar abilities within themselves. Hughes points out that the therapy presupposes that the therapist and parent are able to remain engaged with the children when their attachment schema are activated by the stress of the dyadic interaction and the therapeutic theme. The therapist must explore relevant past experiences of the caregivers to determine if they have the ability to remain present with the child whenever the child is at risk for affective, behavioral, and/or cognitive dysregulation. If the primary caregiver is the past abuser, it is crucial that full responsibility has been accepted otherwise the caregiver cannot be appropriately empathic. However Hughes considers that attachment based treatment can be undertaken with just the therapist.(Hughes 2004 p25)^[3]

Controversy

DDP has been criticised for the lack of a comprehensive manual or full case studies to provide details of the process. In addition, although non-verbal communication, communicative mismatch and repair, playful interactions and the relationship between the parents attachment status and that of a toddler are all well documented and important for early healthy emotional development, Hughes and Becker-Weidman are described as making "a real logical jump" in assuming that the same events can be deliberately recapitulated in order to correct the emotional condition of an older child.^[14] It is also suggested that the therapy appears to use age regression techniques to bring about such recapitulation - a feature of attachment therapy not congruent with attachment theory.^[14] Dr Becker Weidman cites Daniel Hughes 1997 book "Facilitating Developmental Attachment", which contains a section on the use of age regression, as a source document for dyadic developmental psychotherapy.^[8]

Opinion is divided as to whether Dyadic Developmental Psychotherapy is in fact an attachment therapy. The APSAC Taskforce report on Attachment disorder, Reactive attachment disorder and Attachment therapy, published in 2006, places Hughes and Becker-Weidman within the attachment therapy paradigm and indeed specifically cites Becker-Weidman for, amongst other things, the use of age regression, though not for coercive or restraining practices (p. 79). They also describe DDP as an attachment therapy in their November 2006 Reply to Letters.^[10][15] Becker-Weidman had stated in his letter to the Taskforce that it was essential to treat a child at its developmental rather than chronological level, but the Taskforce in its November 2006 Reply to Letters disagreed (p. 382).^[15][16]

The Taskforce in their Reply to Letters describe Hughes as "a leading attachment therapist" and cite Hughes (together with Kelly and Popper) as examples of attachment therapists who have more recently developed their practices away from the more concerning attachment therapy techniques (p. 383).^[15] Indeed they use Hughes' list of specific techniques that he believes should be or have been excluded from the practice of DDP as an example of concerning treatment behaviors.^[17]

The Kansas University/SRS Best Practices Report (2004) considered that dyadic developmental psychotherapy as described by Becker-Weidman, appeared to be somewhat different from that as described by Hughes. They state that in 2004 Becker-Weidman's claim that dyadic developmental psychotherapy was 'evidence based' cited studies on holding therapy by Myeroff, Randolph and Levy from the Attachment Center at Evergreen.^[18][19] Hughes' model is described as more clearly incorporating researched concerns about 'pushing' children to revisit trauma (as this can re-traumatize victims) and as having integrated established principles of trauma treatment into his approach. Avoiding dysregulation is described by Hughes as a primary treatment goal.^[18]

The advocacy group Advocates for Children in Therapy include dyadic developmental psychotherapy in their list of "attachment therapies by another name", and continue to list Hughes as a proponent of attachment therapy citing material relating to holding therapy from earlier publications in addition to Hughes more recent works.[5] In particular, they cite material from Hughes website about the use of physical contact in therapy as follows:

"To be effective, the child must be engaged by the therapist at the level of preverbal attunement rather than in a setting of rational discussions. The therapy must also involve a great deal of physical contact between the child and the therapist and parent. During much of the most intense therapeutic work, the child is being touched or held by the therapist or parent. His intense emotions are received, accepted, and integrated into the self. Within a therapeutic atmosphere based on attunement, he is able to begin to explore aspects of himself and his relationships with his parents that have previously not been accessible. The development of both the child's attachment to his parents and his integrated self is the primary goal of the therapist; all else is secondary."^[20]

Dr Becker-Weidman cites Daniel Hughes 1997 book "Facilitating Developmental Attachment", which contains a chapter on the use of holding therapy, as a source book for dyadic developmental psychotherapy.^[20]

According to the author of this ^[21] article on dyadic developmental psychotherapy "Holding is one of the experiential methods used, but it is not a restrictive, invasive, or constricting holding. The holding used is better described as cradling much as one would cradle an infant or toddler. Cradling creates a multi-sensory experience to facilitate attunement, emotional reciprocity and stability, enhances empathic responses, safety and re-enactment of the nurturing holding of infancy to provide a corrective cognitive-emotional experience." According to Hughes's website,

"The child may be held at home or in therapy for the purpose of containment when the child is in a dysregulated, out-of-control state only when less active means of containment are not successful in helping him/her regain control, and only as long as the child remains in that state. The therapist/parent's primary goal is to insure that the child is safe and feels safe. The goal is never to provoke a negative emotional response or to scold or discipline the child. The model for this type of holding is that of a parent who holds an overtired, overstimulated, or frightened preschool child and helps him/her to regulate his distress through calm, comforting assurances and through the parent's own accepting and confident manner." ^[22]

Prior and Glaser state that Hughes's therapy 'reads' as good therapy for abused and neglected children, though with 'little application of attachment theory' but do not include it in their section on attachment therapy.^[23]

Trowell, while admiring Hughes's clinical skills, stated that "Parents and carers need their own specific parent work and the children and young people need specific work tailored to their needs ... parents with their own unmet attachment needs from childhood may significantly inhibit their ability to speak frankly with, and feel supported by professionals aiming to help their children".^[24] Referring to the use of facial expressions in attempts at attunement, Trowell noted, "although the therapist may look and feel sad, the young person may see this as a provocation-- either hit out or the therapist may be perceived to be triumphant (the facial expression may be misread)" (p. 281). Trowell emphasized the value of many of Hughes's ideas for clinical work, but she concluded that "There is a need for caution. Experienced, well-trained clinicians can, with supervision, take these ideas forward into their clinical practice. But the ideas in [Hughes's 2004 paper] do not provide a sufficient basis for a treatment manual, and are not to be followed uncritically."

Evidence

In two studies by Becker-Weidman, the second being a four year follow up of the first, dyadic developmental psychotherapy was reported to be an effective treatment for children with complex trauma who met the DSM IV criteria for Reactive attachment disorder.^[8][9] The first study concluded that children who received dyadic developmental psychotherapy had clinically and statistically significant improvements in their functioning as measured by the Child Behavior Checklist (Achenbach [6]), while the children in the control group showed no change one year after treatment ended. The study also used the Randolph Attachment Disorder Questionnaire as a measure.^[8] Statistical comparisons employed multiple t-tests rather than analysis of variance, and no tests for homogeneity of variance were reported.

The treatment group comprised thirty-four subjects whose cases were closed in 2000/01. This was compared to a 'usual care group' of thirty subjects. The published reports on this work do not specify the nature of "usual care" or clarify why the "usual care" group, who were assessed at Becker-Weidman's clinic, did not have treatment there. Treatment consisted of an average of twenty three sessions over eleven months. The findings continued for an average of 1.1 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 1.3 years after the evaluation was completed. 82% of the treatment-group subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes.

In the follow-up study the results from the original study were maintained an average of 3.9 years after treatment ended. There were no changes in the usual care-group subjects, who were re-tested an average of 3.3 years after the evaluation was completed.

Becker-Weidman's first (2006) study was considered by the APSAC Taskforce in their November 2006 Reply to Letters following their main report on attachment therapy.^[15] The Taskforce had in their original report criticised Dr Becker-Weidman for claiming an evidence base to his therapy, and indeed for claiming to be the only evidence based therapy, where the Taskforce considered no evidence base existed.^[10] Dr Becker-Weidman responded to this with an open letter citing his study.^[25] The Taskforce examined the (2006) study, criticized the methodology and stated that although the study was an important first step towards learning the facts about DDP outcomes, it fell far short of the criteria that must be met before designating a treatment as evidence based.^[26]

Between the Taskforce report and Reply to Letters, Craven & Lee (2006) undertook a literature review of 18 studies of interventions used for foster children and classified them under the controversial Saunders, Berliner, & Hanson (2004) system.^[12][27][28] They considered only two therapies aimed at treating disorders of attachment, each of which was represented by a single study: dyadic developmental psychotherapy and holding therapy.^[29][30] They placed both in Category 3 as "supported and acceptable". This classification means that the evidence basis is weak, but that there is no evidence of harm done by the treatment. The Craven & Lee classification report has been criticized as unduly favourable (Pignotti & Mercer 2007 ^[14] ) This critique noted the absence of a comprehensive manual giving details of the dyadic developmental psychotherapy intervention - one of the necessary criteria for assessment using the Saunders et al. guidelines, and one without which no outcome study can be placed in any of the available categories. Craven and Lee rebutted this paper in a reply that concentrated on holding therapy rather than dyadic developmental psychotherapy.^[31]

It also appears from the studies that accompanying attachment therapy parenting techniques from sources such as Facilitating Developmental Attachment (1997) by Daniel Hughes, and works by Nancy Thomas and Deborah Hage were used.^[8][9][20]

In Hughes' own work,^[32] the children being treated are not identified as diagnosed with Reactive Attachment Disorder, but as having a "rigid self-reliance that becomes a compulsive need to control all aspects of their environment" (p. 263). Hughes comments that "Such children present a diagnostic puzzle" (p. 263). The Becker-Weidman material presents only a diagnostic category rather than describing specific behavioral and emotional disturbances.

The results of Becker-Weidmans studies have been recently republished.^[33]

See also

• Attachment-based therapy (children)
• Attachment theory
• Attachment in children
• Attachment therapy
• Attachment disorder
• Reactive attachment disorder
• Complex post-traumatic stress disorder

References

1. ^ 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
2. ^ Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279
3. ^ ^{a b c d e f g h i} Hughes D (2004). "An attachment-based treatment of maltreated children and young people". Attachment & Human Development 3: 263–278. http://www.attachmentcoalition.org/DDP.pdf. 
4. ^ Bretherton, I.,(1992) "The origins of attachment theory," Developmental Psychotherapy, 28:759-775.
5. ^ Holmes, J.(1993) John Bowlby and Attachment Theory, London:Routledge ISBN 0-415-07729-X
6. ^ Stern, D.,1985"> Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic
7. ^ Tronick, E., & Gianino,A.,1986"> Tronick, E.,& Gianino, A. (1986). "Interactive mismatch and repair". Zero to Three, 6(3):1-6.
8. ^ ^{a b c d e} Becker-Weidman. Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2), April 2006
9. ^ ^{a b c} Becker-Weidman, A., (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova
10. ^ ^{a b c} Chaffin, M. et al. (2006) Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment problems. | Journal= Child Maltreatment 2006;11;76| page=78 | DOI: 10.1177/1077559505283699 |
11. ^ Mark Chaffin, Rochelle Hanson and Benjamin E. Saunders Reply to Letters Child Maltreat 2006; 11; 381 DOI: 10.1177/1077559506292636
12. ^ ^{a b} 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.
13. ^ Daniel Hughes website, retrieved 11th September 2007
14. ^ ^{a b c} Pignotti, M., & Mercer, J. (2007). Holding Therapy and Dyadic Developmental Psychotherapy are not supported and acceptable social work interventions: A systematic research synthesis revisited. Research on Social Work Practice, 17 (4), pp. 513-519.
15. ^ ^{a b c d} Mark Chaffin, Rochelle Hanson and Benjamin E. Saunders | Reply to Letters | Child Maltreat 2006; 11; 381 | DOI: 10.1177/1077559506292636 "Dr. Becker-Weidman is cited three times in the body of the report, none of which refer to coercive techniques. The first citation references his Web site’s assertion that traditional therapies are either ineffective or harmful (p. 78). The second citation references his recommendation that children be encouraged to regress to an earlier age as part of treatment (p. 79). The third citation references his assertions, which we believe are unsupported, about practicing an evidence-based treatment (p. 85)."
16. ^ Arthur Becker-Weidman, Letter to the Editor, Child Maltreat 2006; 11; 379, DOI: 10.1177/1077559506292632.
17. ^ Hughes, D. (2002, November 30). Treatment and parenting model. Retrieved July 3, 2006, from http://danielahughes.homestead.com/Model~ns4.html
18. ^ ^{a b} Uta M. Walter,U.,M. and Petr,C. Best Practices in Children’s Mental Health: “Reactive Attachment Disorder: Concepts, Treatment and Research” Produced by the University of Kansas School of Social Welfare in conjunction with Kansas Social Rehabilitation Services pp 10-18
19. ^ Becker-Weidmann, A. (3/7/2004). Dyadic Developmental Psychotherapy, retrieved 3/20/2004 from http://www.center4familydevelop.com/developmentalpsych.htm
20. ^ ^{a b c} Daniel A. Hughes, Facilitating Developmental Attachment: The Road to Emotional Recovery and Behavioral Change in Foster and Adopted Children. 1997. Publisher Jason Aronson Inc. [1] retrieved 12th September 2007.
21. ^ Kim Cross LSCSW Kansas Attachment Center [2] retrieved 12th September 2007
22. ^ [3] D.Hughes website, retrieved 10th September 2007
23. ^ Prior, V., and Glaser, D. (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice, Jessica Kingsley Publishers, Child and adolescent mental health series. | p268 | ISBN 1 84310 245 5.
24. ^ Trowell, J. (2004). Reflections on 'an attachment-based treatment of maltreated children and young people'. Attachment & Human Development, 6(3), 279-283
25. ^ Arthur Becker-Weidman | Letter to the Editor | Child Maltreat 2006 No 11 | p379 |
26. ^ "In our estimation, DDP still does not meet criteria as an evidence-based treatment, although the published findings do raise hopes that DDP may be promising. Examining the study, it shares many of the same limitations noted in the Task Force’s evaluation of the Myeroff study (p. 85). For example, the study used a small convenience sample, participants were self-selected into treatment versus comparison conditions, the age range of participants was very broad (5-16), there was no direct statistical analysis of differential group change over time, outcome data were not collected by blind or impartial reporters, and the study utilized completer only rather than intent-to-treat methods. Of course, no study is without limitations; however, the fact remains that a single study with these sorts of major limitations, although a first step, is far short of the criteria that must be met before designating a treatment as evidence based. In general, we believe that designating a treatment as evidence based is a job for an independent treatment review panel (e.g., American Psychological Association, Substance Abuse and Mental Health Services Administration [SAMHSA], Office for Victims of Crime Task Force, Cochrane Collaborative, etc.) applying accepted and established scientific review criteria. None has listed DDP as meeting accepted criteria. Thus, it is our opinion that practitioners should not characterize or advertise DDP as an evidence-based practice at this time." Reply to Letters p3.
27. ^ Saunders, B.E., Berliner, L., & Hanson, R.F. (Eds.). (2004). Child Physical and Sexual Abuse: Guidelines for Treatment (Revised Report: April 26, 2004). Charleston, SC: National Crime Victims Research and Treatment Center. [4] Quote "Category 1: Well-supported, efficacious treatment; Category 2: Supported and probably efficacious; Category 3: Supported and acceptable; Category 4: Promising and acceptable; Category 5: Novel and experimental; and Category 6: Concerning Treatment"
28. ^ Gambrill, E., (2006). Evidence based practice and policy: Choices ahead. Research on Social Work Practice, 16, pp338-357
29. ^ Becker-Weidman, A. (2004). Dyadic developmental psychotherapy: An effective treatment for children with trauma-attachment disorders. Retrieved May 10, 2005 from http://www.Center4familyDevelop.com
30. ^ Myeroff et al. (1999)Comparative effectiveness of holding therapy with aggressive children. Child Psychiatry and Human Development, 29, 303-313
31. ^ Lee, R.E., & Craven, P. (2007). Reply to Pignotti and Mercer: Holding Therapy and Dyadic Developmental Psychotherapy are not supported and acceptable social work interventions. Research on Social Work Practice, 17(4), pp 520-521.
32. ^ Hughes, D. "An attachment-based treatment for maltreated children and young people" (2004) Attachment & Human Development, 6, 263-278
33. ^ 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.