Dyadic developmental psychotherapy

Dyadic developmental psychotherapy is an evidence-based treatment (classed as an acceptable and supported social work intervention under the criteria suggested by Saunders, Berliner, & Hanson (2004) )   approach for the treatment of attachment disorder, Complex Post Traumatic Stress Disorder, and reactive attachment disorder. It was originally developed by psychologist Dr. Daniel Hughes, as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers. Hughes developed Dyadic developmental psychotherapy with the express intention of developing a therapy removed from the coercive practices of attachment therapy. Hughes cites attachment theory and particularly the work of John Bowlby as the theoretical basis for dyadic developmental psychotherapy. . Other sources for this approach include the work of Stern, who referred to the attunement of parents to infants' communication of emotion and needs, and of Tronick , who discussed the process of communicative mismatch and repair, in which parent and infant make repeated efforts until communication is successful. Children who have experienced pervasive and extensive trauma, neglect, loss, and/or other dysregulating experiences may benefit from this treatment. Children who have experienced pervasive and extensive trauma, neglect, loss, and/or other dysregulating experiences can benefit from this treatment.

The treatment meets the standards 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' standards for the evaluation and treatment of children and adolescents. This is a non-coercive treatment. The principles and methodology of Dyadic Developmental Psychotherapy are based on long-standing treatment principles supported by some nonrandomized research evidence. This is a non-coercive treatment.

The basic principles of Dyadic Developmental Psychotherapy are grounded in well established treatment principles for the treatment of complex trauma:
 * 1) Safety
 * 2) Self-regulation
 * 3) Self-reflective information processing
 * 4) Traumatic experiences integration
 * 5) Relational engagement
 * 6) Positive affect enhancement

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.

Two empirical studies concluded that the treatment was more effective for the treatment of reactive attachment disorder and emotional trauma than "usual treatments" although there has been some criticism of the research.

In addition, many of the components of Dyadic Developmental Psychotherapy are based on sound clinical principles from Child Development research and treatment. These include respect for the client, attunement, developing reflective abilities, and related components.

Theoretical basis
Dyadic Developmental Psychotherapy is based on Attachment theory; Dr. Hughes cites Lyons & Jacobvitz (1999). Caregivers of maltreated children are seen as a source of fear which leads to a substantial disruption in the attachment system Such children may also suffer intrusive memories secondary to trauma and as a result may have difficulty participating in treatment.

It is stated that once an infants safety meeds are met (by attachment) they focus on learning and responding to the social and emotional signals 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. 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, children co-construct the meaning of their experience and co-regulate their affective response, with their carer. This leads to the capacity for self awareness and eventually development of autonomy.

The therapy attempts to remediate this early trauma by helping create intersubjective experiences between parent and child that will remediate those earlier trauma's and correct the distorted developmental trajectory.

Methodology
Dyadic Developmental Psychotherapy is an effective and evidence-based treatment developed by Daniel Hughes, Ph.D.,  Its basic principals are described by Hughes and summarized as follows:


 * 1) A focus on both the caregivers' and therapists' own attachment histories.  Previous research  has shown the importance of the caregivers' and therapists' state of mind for the success of interventions.
 * 2) 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.
 * 3) Sharing of subjective experiences.
 * 4) Use of PACE (Playfulness, Acceptance, Curiosity and Empathy) and PLACE (Playful, Loving, Accepting, Curious, and Empathic) strategies are essential to healing.
 * 5) Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.
 * 6) Caregivers use attachment-facilitating interventions.
 * 7) Use of a variety of interventions, including cognitive-behavioral strategies.

PACE refers to the therapist setting a healing pace by being playful, accepting, curious, and empathic. PLACE refers to the parent creating a healing environment by being playful, loving accepting, curious, and empathic. These ideas are described more fully below.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory, developed by Bowlby provides the theoretical foundation for Dyadic Developmental Psychotherapy. . It relies on sound treatment principles based on empirical evidence, such as the importance of empathy, reflective function, and other general treatment principles.

This treatment has been found to produce measurable and sustained improvement in children diagnosed with Reactive Attachment Disorder. In that study it was found that other forms of treatment, such as individual therapy or play therapy did not produce any improvement; thus indicating that Dyadic Developmental Psychotherapy is effective while other forms of treatment are not effective for this disorder. Hughes, stated that the children being treated are described 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).

Dyadic developmental psychotherapy involves creating a safe setting in which the client can begin to explore, resolve, and integrate a wide range of memories, emotions, and current experiences, that are frightening, stressful, avoided or denied. Safety is created by insuring that this exploration occurs with nonverbal attunement, reflective, non-judgmental dialogue, along with empathy and reassurance. As the process unfolds, the client is creating a coherent life story or autobiographical narrative that is crucial for attachment security and is a strong protective factor against psychopathology. Therapeutic progress occurs within the joint activities of co-regulating affect and co-constructing meaning.

Attunement
Intersubjectivity is an essential component of this treatment. Nonverbal attunement refers to the frequent interactions between a parent and infant, in which both are sharing affect and focused attention on each other in a way such that the child's enjoyable experiences are amplified and his/her stressful experiences are reduced and contained. This is done through eye contact, facial expressions, gestures and movements, voice tone, timing and touch. These same early attachment experiences, which are fundamental for healthy emotional and social development, are utilized in therapy to enable to the client to rely on the therapist to regulate emotional experiences and to begin to understand these experiences more fully. Such understanding develops further through engaging in a conversation about these experiences, without judgment or criticism. The therapist will maintain a curious attitude about the memories and behaviors, encouraging the client to explore them to better understand their deeper meanings in his life and gradually develop a more coherent life-story. This process may be stressful for the client, so the therapist will frequently "take a break" from the work, provide empathy for the negative emotion that may be elicited, and reassure the client about his efforts and the therapeutic relationship.

The primary therapeutic attitude demonstrated throughout the sessions is one of PACE.

For the purpose of increasing the client's safety, his/her readiness to rely on significant attachment figures in his life, and his/her ability to resolve and integrate the dysregulating experiences that are being explored, a person who an important attachment figure to the client will be actively present. When the client is a child, this most often will be the child's parent or guardian. When the client is an adult, this most often will be the adult's partner.

Role of parents in treatment
The role of the parent in his/her child's psychotherapy is the following:


 * 1) Help him to feel safe.
 * 2) Create a healing PLACE, both nonverbally and verbally.
 * 3) Help him to regulate any negative affect such as fear, shame, anger, or sadness.
 * 4) Validate his/her worth in the face of trauma and shame-based behaviors.
 * 5) Reassure him/her that your relationship remains strong regardless of the issues.
 * 6) Help him/her to make sense of his/her life so that it is organized and congruent.
 * 7) Help him/her to understand your perspective and motives with respect to him/her.

The parent's role is not to criticize, lecture, nag, or amplify shame. Periodic confrontation may be necessary and needs to be integrated into the overall treatment session. Reassurance and repair of the relationship after confrontation is crucial. The child will not participate fully in therapy, and will not benefit much from the process if s/he does not feel safe in a setting primarily characterized by PACE.

It is stated that a person's symptoms are that person's unsuccessful ways of regulating frightening or shame-based memories, emotions, and current experiences. Angrily telling a person to stop engaging in these symptoms may actually increase their underlying causes. In helping the child in therapy and at home to regulate the affect associated with the symptoms, and to understand the deeper meanings of the symptoms, we are increasing the likelihood that the symptoms will decrease. At the same time it may certainly be necessary to address the symptoms through increased supervision or through applying natural consequences for them. Again, however, the issues will be addressed more effectively when done with PACE rather than habitual anger, rejection, or other shame-inducing actions.

When we are asking a client to address frightening or shame-based memories, emotions, and current experiences, when are asking him/her to engage in an activity that will be emotionally painful. In do so it is crucial that we maintain an attitude characterized by PACE in order to insure that the client is not alone while entering that painful experience. The client has developed significant symptoms and defenses against that pain, most often because s/he was alone in facing it. When we help to carry and contain the pain with him/her, when we co-regulate it with him/her, we are providing him/her with the safety needed to explore, resolve, and, integrate the experience. We do not facilitate safety when we support a client's avoidance of the pain, but rather when we remain emotionally present when he is addressing the pain.

Features of Dyadic Developmental Psychotherapy
The following statements reflect routine features of dyadic developmental psychotherapy:


 * 1) Playful interactions, focused on positive affective experiences, are never forgotten as being an integral part of most treatment sessions, when the client is receptive.  When the client is resistant to these experiences, the resistance is met with PACE.
 * 2) Shame is frequently experienced when exploring many experiences of negative affect.  Shame is always met with empathy, before considering interventions to question it.
 * 3) Emotional communication that combines nonverbal attunement and reflective dialogue and is followed by relationship repair when necessary is the central therapeutic activity.
 * 4) While supporting the reduction of shame, we also support the increase of guilt.
 * 5) Resistance is met with PACE, rather than being criticized and/or punished.
 * 6) Treatment is directive and client-centered. Directives are frequently modified, delayed, or set aside in response to resistance which is met with PACE.

Dyadic developmental psychotherapy involves the process having a conversation with the client and his/her attachment figure about a wide range of memories, emotions, and current experiences. This conversation occurs within the safety created by nonverbal attunement, reflective dialogue, and interactive repair.

The purpose of this dyadic conversation is to facilitate the development of a coherent autobiographical narrative that involves:


 * 1) Co-regulation of affect elicited during the conversation.
 * 2) Dyadic construction of meaning regarding the focus of the conversation.
 * 3) Development of a sense of efficacy regarding being able to have a conversation about the full range of experiences, memories and emotions in one's personal narrative.

To facilitate this process the therapist will consisting maintain an attitude that involves communicating Playfulness, Acceptance, Curiosity and Empathy (PACE).

A major component of Dyadic Developmental Psychotherapy is its focus on helping the client develop an increased capacity to regulate affect. Affect or emotional dysregulation is a hall-mark of Complex Post Traumatic Stress Disorder. Affect regulation is the relative ability to tolerate painful affect, also known as affect tolerance, and affect modulation, which is the ability to internally reduce distress without resort to defensive mechanisms.

Stages of dyadic developmental psychotherapy

 * 1) Discovery of Process: Provide Information and Experience.
 * 2) Ambivalence about Process: Conversation about certain experiences, memories, and emotions are consistently avoided. Conversation reduces loneliness, confusion, and shame, while eliciting fear of vulnerability, dependence, and inadequacy.
 * 3) Trust of Process: Client is beginning to experience improved abilities to co-regulate affect, to co?create meanings and representations, and to establish a sense of efficacy for establishing a coherent narrative and secure attachments.
 * 4) Utilization of Process: Client is beginning to engage in similar conversations with significant attachment figures outside of therapy.

Standards
Dyadic Developmental Psychotherapy meets the standards and is incompliance with the American Association for the Abuse of Children's (APSAC) Task Force's recommendations and the American Academy of Child and Adolescent Psychiatry practice parameters. In addition, the practice of Dyadic Developmental Psychotherapy is consistent with the practice standards of the American Psychological Association and the National Association of Social Workers.

Dyadic Developmental Psychotherapy is described as not being a coercive therapy.

Evidence Base
Dyadic Developmental Psychotherapy is an evidence based treatment.

Study 1
One study found that 34 children who received Dyadic Developmental Psychotherapy had clinicially and statistically significant improvements in their functioning as measured by the Child Behavior Checklist Achenbach, while the 30 children in the control group showed no change one year after treatment ended.

This study examined the effects of Dyadic Developmental Psychotherapy on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive attachment disorder. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. Seven hypotheses were explored. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These 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. The results are particularly salient since 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. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 53% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.

This study supports several of O’Connor & Zeanah’s conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.” The results of this study are a beginning toward that end. While there are a number of limitations to this study, given the severity of the disorders in question, the paucity of effective treatments, and the desperation of caregivers seeking help, it is a step in the right direction. Dyadic Developmental Psychotherapy is not a coercive therapy, which can be dangerous. Dyadic Developmental Psychotherapy provides caregiver support as an integral part of its treatment methodologies. Finally, Dyadic Developmental Psychotherapy uses a multimodal approach built around affect attunement. This study concludes that Dyadic Developmental Psychotherapy is an effective intervention for children with trauma-attachment problems.

Study 2
A second study reported the results of a study following these children for four years after treatment ended. This study examined the effects of Dyadic Developmental Psychotherapy, four years after treatment ended, on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These findings continued for an average of 3.9 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 3.3 years after the evaluation was completed. The results are particularly salient since 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. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 100% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.the

Critique of Studies
The author himself makes the point that these are preliminary and exploratory studies. "While the results are intriguing, the small sample size and limited number of families located at this time limit the strength of the findings. (p.44)" A number of points can be made about the design of the studies which may helpful in the planning of further work.

"Evidence-based" is not a unitary concept, and recent thinking has lead to the development of a number of proposed criteria for the assessment of clinical studies.

Although there is currently no universally-accepted definition of the term "evidence-based", the general understanding of this concept involves support of the safety and efficacy of an intervention by empirical research following specific rules of data collection, analysis, and reporting. A number of protocols for evaluation of outcome research evidence have been suggested, and the research reported for DDP can be evaluated in terms of various criteria drawn from these protocols and elsewhere.

1. Basic research design. All protocols accept, but do not require, evidence based on randomized controlled trials as powerfully supportive of treatment efficacy, and others accept clinical controlled trials as appropriate sources of evidence. The outcome research on Dyadic Development Psychotherapy used clinical controlled trials.

2. Details of data collection.

a.Blinding. The research reports do not indicate that pre and post-testing or data analysis were done by staff members who were blind to treatment variables. This precaution is desirable because it prevents inadvertent or intentional errors in the direction of support for the treatment. Of course, parents responding to questionnaires knew what treatment their children had received.

b. Diagnostic measures. These studies employed the well-validated Achenbach Child Behavior Checklist, but also used the Randolph Attachment Disorder Questionnaire, a poorly-developed instrument available only through its originator. Six of the seven scales on the Achenbach (the outcome measures) show statistically significant differences between the pre and post-treatment groups for the treatment group but not the control group, and all seven scales showed clinically significant reductions. The RADQ measure showed statistically and clinically significant reductions between pre- and post-treatment times for the treatment group but not for the control or "usual care," group.

c. Assurance of intervention fidelity. There are several volumes<Becker-Weidman, A., & Shell, D., (2005) Creating Capacity for Attachment. Oklahoma City, OK: Wood 'N' Barens. . that describe some of the steps of Dyadic Developmental Psychotherapy.

3.Data analysis and interpretation.

a. Confounding variables. Interpretation of data from clinical controlled trials requires evidence that the treatment groups did not differ in terms of variables whose effects could be confounded with those of the treatments. The Dyadic Developmental Psychotherapy research studies included a statistical analysis comparing the treatment and control groups on demographic variables, pre-treatment measures of psychopathology, and pre-treatment indicators of previous treatment.

b. Choice of statistical tests. Interpretation of data can only be accurate if it involves a correct choice of statistical test and, of course, accurate calculation. The choice of multiple t-tests for analysis of the outcome data is considered appropriate, although a simple two-way analysis of variance would have been a better choice and could have examined simultaneously the effects of the treatments on outcome measures and the differences between pre- and post-treatment measurements. More complex ANOVA designs could also have dealt with the use of repeated measures.

Theoretical Critique
There has been some criticism by one author and leader of the advocacy group, Advocates for Children in Therapy, of the claim that Becker-Weidman's outcome research provides evidence supporting the effectiveness of DDP. They claim that material about DDP has failed to offer a rationale for the application of the "attunement" concept (part of normal infant-parent interaction) to treatment of emotionally-disturbed older children; thus a genuine theoretical foundation is missing. These authors also claim that the therapy appears to use age regression techniques to bring about such recapitulation. , although there is nothing in the writings about Dyadic Developmental Psychotherapy to support that statement.

These authors claim that Dyadic Developmental Psychotherapy has failed to offer a rationale for the application of the "attunement" concept to treatment of emotionally-disturbed older children; thus a genuine theoretical foundation is missing. They claim that 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. They also claim that the therapy uses age regression techniques to bring about such recapitulation, although there is no basis for this claim.

The Taskforce stated "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."

However, being evidence-based is not a unitary concept, and recent thinking has lead to the development of a number of criteria for the assessment of clinical studies. With the publication of the follow up study we are now in a position to freshly evaluate the studies in this area against the different sets of criteria.

Trowell, while admiring Hughes' 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" (p. 279). 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' 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' 2004 paper] do not provide a sufficient basis for a treatment manual, and are not to be followed uncritically."

Although they do not respond to all Trowell's concerns, more detailed specifications of techniques, methodology, and use can be found in more recent publications

Proposals for further research
To build on the research conducted to date an independent replication would be important. This should include: procedures for ensuring for the blind random assignment to treatment conditions; improved statistical processing of the results.