Dyadic Developmental Psychotherapy: What it is and What it isn't
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
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.
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
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
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.
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.
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.
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.
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
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.
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.