SELECTED ARTICLE
Author
Arthur Becker-Weidman, Ph.D. 
Article Title
Dyadic Developmental Psychotherapy: What it is and What it isn't 
Posted Date
11/14/2005 

There are many misconceptions and fictions about treatments for trauma-attachment disordered children. Is treatment dangerous and deadly? Is it a miracle cure? What, exactly, is attachment therapy? First, some truths. Dyadic Developmental Psychotherapy is the only form of treatment that is effective with trauma-attachment disordered children. It is the only “evidence-based” treatment, meaning that there has been research published in peer-reviewed journals. In an on-going follow-up study we found that 1.1 years after treatment ended, there were statistically and clinically significant reductions in aggressive, delinquent, avoidant, and other symptoms. It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Dyadic Developmental Psychotherapy is primarily an experiential-based treatment, designed to facilitate experiences of safety and security so that a secure attachment may grow. Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment.

Dyadic Developmental Psychotherapy is the name for an approach and a set of principles that have proven to be effective in helping trauma-attachment disordered children heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principles. These principles are based on the causes and courses of disorders of attachment.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first two years to three years of life. These experiences disrupt the normal attachment process so that the child’s capacity to form a secure attachment with a caregiver is distorted or absent. The child lacks trust, safety, and security. The child develops a negative working model of the world in which:

  • Adults are experienced as inconsistent or hurtful.
  • The world is viewed as chaotic.
  • The child experiences no effective influence on the world.
  • The child attempts to rely only on him/her self.
  • The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

First Principle.

Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are the “active ingredient” in the healing process. Traumatized children who are unable to trust do not respond to traditional forms of treatment such as play therapy, residential treatment, or talk therapies, since these therapies require and work through a relationship between the therapist and client.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way.

    My first therapy was with Dr.Steve. The therapy was FUN!!!! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

    Dr. Steve taught me how to play and have fun with my Mom. But I still didn't know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

    Going to see Dr. Art Dr.

    Art wanted me to take off my shoes. He wanted me to put them on the table. I didn't want to do it. I got mad at Dr. Art because I didn't want to do what he said. I always wanted to be the boss. But Dr. Art was being the boss. I didn't know what to do. Then I made a plan to not do therapy. I would get so mad and scared that I wanted to hurt Dr. Art. I tried to hit, kick, and spit. I tried to break stuff. Dr. Art kept me safe. But back then it just made me madder. Sometimes in therapy I would just copy what Dr. Art said. I was trying to be in charge and get Dr. Art mad. But then Dr. Art just started copying me. Then I would get madder. But pretty soon Dr. Art would make me laugh. I tried lots of other tricks to make Dr. Art mad. But my tricks didn't work. I would get so mad.

    Stuff Dr. Art Taught Me

    I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can't overflow because I let some of the feelings out.

    I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn't take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn't because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn't get hurt anymore. But the bricks kept the love out too. I wouldn't let Mom's love in. I had lots of mad in my heart.

    My hard work in therapy got rid of all the bricks. Then Mom's love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

    I really liked Dr.

    Art now and am proud that I am strong. I still don't need therapy. I still let Mom's love into my heart!!!!!! Sometimes I send e-mail’s to Dr. Art. I tell him how good I'm doing.

    I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom "I don't need therapy. I just want to have lunch with Dr. Art." So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together. Sometimes it's still hard. I still get mad and sometimes I don't express my feelings well. Sometimes when Mom helps me ? I can express my feelings and say "I don't want to pick up my toys. It makes me mad that I have to ? but I will". When I say that it doesn't make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

    It's been a really longtime since I tried to hurt Mom or break things when I'm mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don't feel like I'm a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

Second Principle.

Therapy must be family-focused. Therapy opens up a child so that what the parents have to offer can get in and heal the child. It is the parents’ capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the “attitude ” that heals. Parents are actively involved in treatment. They are either in the session with the child on the parent’s lap or watching the therapy through a one-way mirror or by closed circuit TV. This is essential. It ensures that the parents are actively and fully involved in treatment.

Third Principle.

The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child’s trauma. Revisiting the trauma is essential if the child is to begin to revise the child’s personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

Fourth Principle.

A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. “Compression-wraps,” invasive and intrusive stimulation designed to evoke rage, “re-birthing,” and other provocative techniques are not part of attachment therapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principle.

Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment. A child may be restrained if the child is about to hurt him/her self, destroy property, or hurt the therapist. 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 helps promote a safe, secure, and comforting milieu. Parents review and sign a detailed informed consent document, as do teenagers. In the first session all children identify something that the child wants different about the child’s life; that is the basis for a consensual relationship.

The therapist must be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh. In selecting a therapist you should look for the following:

  • Significant training from a recognized training program. I would recommend at least one-week of prior training followed by regular supervision of videotapes. Ask where the therapist was trained, how long ago, and for how long.
  • An office set-up so that sessions are videotaped and parents can watch sessions from another room if not actually in the room.
  • Ongoing training. Ask when was the last training event the therapist attended and how long was the event.
  • Licensure in the state in a recognized mental health discipline.
  • Membership in ATTACh.
  • A comprehensive informed consent document and appropriate releases.
  • An initial assessment to develop a differential diagnosis and treatment plan.
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. Only an experienced and trained therapist can provide attachment therapy.
References
Arthur Becker-Weidman, Ph.D. Center For Family Development 5820 Main Street, suite 406 Williamsville, NY 14221 716-810-0790 Aweidman@Concentric.net WWW.Center4FamilyDevelop.com

Creating Capacity for Attachment, edited by Arthur Becker-Weidman,Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, 2005. “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 12 #6, December 2005. 
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