Dyadic Developmental Psychotherapy: What it Is and What it Isn’t

Closeup of a little girl smiling at the camera

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 Dyadic Developmental Psychotherapy? First, some truths. Affective Developmental psychotherapy and other attachment therapies are 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 journals1. In an on-going follow-up study we found that 1.3 years after treatment ended, there were statistically significant reductions in aggressive, delinquent, avoidant, and other symptoms7.  Affective 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, an attachment-based therapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy, an attachment-based therapy is a family-focused treatment.

Dyadic Developmental Psychotherapy, an attachment-based therapy, is the name for an approach and a set of principals that have proven to be effective in helping trauma-attachment disordered children heal; that is, develop healthy, trusting, and secure relationships with caregivers. Dyadic Developmental Psychotherapy, an attachment-based therapy is based on five central principals. These principals 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 PRINCIPAL. 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 Dyadic Developmental Psychotherapy, an attachment-based therapy this way:

My first therapy was with Dr. Max. 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. Max. said.

Dr. Max. 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 like 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, playful and nurturing activities, and other exercises. One key element is maintaining emotional attunement with the child through PACE; being Playful, Accepting, Curious, and Empathic.

SECOND PRINCIPAL. 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 PRINCIPAL. 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 PRINCIPAL. 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 Dyadic Developmental Psychotherapy, an attachment-based therapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

FIFTH PRINCIPAL. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment. A child may be restrained is 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 a 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 Dyadic Developmental Psychotherapy, an attachment-based therapy.

Resources

  1. Comparative Effectiveness of Holding Therapy with Aggressive Children, by Robin Myeroff, Ph.D., Gary Mertlich, Ph.D., & Jim Gross, MA, Child Psychiatry and Human Development, Vol. 29 (4), summer 1999, pp 303-313.
  2. Does Dyadic Developmental Psychotherapy, an attachment-based therapy Work? Results of Two Preliminary Studies, Second Edition. Published by Association for Teaching and Training in the Attachment of Children, available via WWW at http://web.archive.org/web/20141210052316/http://www.attach.org/Pages/researchrandolph.html also available from The Attachment Center Press.
  3. Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology, 60, 733-747, 1992.
  4. Handbook of Attachment: Theory, research, and Clinical Applications, edited by J. Cassidy & P. Shaver, 1999.
  5. Handbook of Attachment Interventions, edited by Terry Levy, Ph.D., 2000.
  6. Attachment, Trauma, and healing: understanding and treating attachment disorder in children and families, 1998, Child Welfare League of America press
  7. Affective Developmental Psychotherapy with Trauma-Attachment Disordered Children, Arthur Becker-Weidman, Ph.D., article submitted for publication (see www.Center4FamilyDevelop.com 2002). All children in the study who had RADQ scores above 65 had scores reduced below the cut-off for reactive attachment disorder. Average score before treatment was 65 average post treatment score was 14. Scores on the Child Behavior Checklist on the Withdrawn, Thought Disorder, Delinquent, and Aggressive subscales were reduced from the “clinical level” to the “normal level.” These reductions were statistically significant.

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