Title: Exploring Dyadic Developmental Psychotherapy
1Exploring Dyadic Developmental Psychotherapy
- Attachment focused therapy for children
experiencing difficulties feeling secure with
caregivers - Kim S. Golding
2Attachment 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.
3The 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).
4Attachment-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.
5Attachment-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.
6Evidence 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.
7Theoretical 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.
-
8Theoretical 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).
11Bowlbys 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).
12The 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.
13Barriers 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).
14Those 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)
15Theoretical 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).
18Primary 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).
19Secondary 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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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.
22Therapy
- 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).
23Theoretical PrinciplesTrauma
24Developmental 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).
25Neurosequential 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).
26Self-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).
27Self-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.
28Intervention 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.
29Intervention 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.
30DYADIC DEVELOPMENTAL PSYCHOTHERAPYClinical
Principles
31Dyadic 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.
32The 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.
33The Therapist
- Maintains and models The Attitude
- Playful.
- Acceptance.
- Curious.
- Empathic.
34The 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.
35The 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.
36The 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.
37Techniques
- 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.
38Techniques
- 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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40PACE
- 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.
41PACE
- 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.
42PACE
- 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).
43Co-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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45Co-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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47Parenting to Support DDP
48Parenting 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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50Understanding and Managing Shame
- DDP actively facilitates the experience of
safety necessary for child to remain engaged in
exploring and resolving experiences of shame.
51Understanding 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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53Child 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.
54Shame 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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56When 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.
57When 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.
58Shame 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.
59Shame 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.
60The 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.
61The 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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63References
- 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
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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.
64References
- Clarke A Clarke A (2000) Early Experience and
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Siegel Chapter 6. p221-281.
65References
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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
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SpringerPublCo. 2nded. (1sted 1989).
66References
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