Dyadic Developmental Psychotherapy

Overview
Dyadic Developmental Psychotherapy is a treatment approach for adopted or fostered children who are thought to have symptoms of emotional disorders. It was originally developed by Daniel Hughes as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers. Hughes cites attachment theory and particularly the work of John Bowlby as theoretical motivations for dyadic developmental psychotherapy. . However, 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.

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. The "dyad" referred to must eventually be the parent-child dyad, but it is unclear how the transition is made from therapist-child to parent-child interactions. Two studies by Arthur Becker-Weidman concluded that dyadic developmental therapy is more effective than the "usual treatment methods" for reactive attachment disorder and complex trauma. According to the APSAC Taskforce Report and Reply, (Chaffin et al 2006), dyadic developmental psychotherapy does not meet the criteria for designation as "evidence based", but the approach has been described as a "supported and acceptable" treatment approach in a meta-analysis and systematic research synthesis evaluating treatment for foster children, (Craven & Lee 2006). . Becker-Weidman and Hughes state that dyadic developmental psychotherapy meets the standards for non-coerciveness 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 concerned with treatment of children and adolescents. Hughes website contains a list of attachment therapy techniques specifically forsworn by him.

Theoretical basis
Dyadic developmental psychotherapy is based on the theory that maltreated infants not only frequently have disorganized attachments but also, as they mature, are likely to develop rigid self-reliance that becomes a compulsive need to control all aspects of their environment. Hughes cites Lyons-Ruth & Jacobvitz (1999) in support of this theory. Caregivers are seen as a source of fear with the result that children endeavour to control their caregivers through manipulation, overcompliance, intimidation or role reversal in order to keep themselves safe. Such children may also suffer intrusive memories secondary to trauma and as a result may be reluctant or unwilling to participate in treatment. It is anticipated that such children will try to actively avoid the exposure involved in developing a therapeutic relationship and will resist being directed into areas of shame and trauma. Hughes proposes that an attachment based treatment may be more effective for such foster and adoptive children than traditional treatment and parenting interventions.

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

The therapy attempts to replicate this or fill in the missing gaps in a maltreated childs experience.

Methods
Firstly the therapist becomes 'non-verbally attuned' with the childs affective state. The therapist then attempts to explore 'themes' with the child whilst remaining attuned. Whilst this is done, the therapist then 'co-regulates' the child’s emerging affective states with 'matched vitality affect', and develops secondary affective/mental representations of them which is co-constructed with the child for purposes of integration. According to Hughes "The therapist allows the subjective experience of the child to impact the therapist. The therapist can then truly enter into that experience and from there express her/his own subjective experience. As the therapist holds both subjective experiences, the child experiences both.  As the child senses both, the child begins to integrate them and re-experience the event in a way that will facilitate its integration and resolution." Hughes (2004) In the anticipated frequent disruptions, due to the childs traumatic and shaming experiences, the therapist accepts and works with these and then 'repairs' the relationship.

This 'nonverbal dance' should run through both positive and negative experiences. It is posited that maintaining/re-establishing attunement during negative affective experiences prevents the child from entering into a state of affective, behavioral, and cognitive dysregulation. The aim is for the therapist and child to develop a new common meaning for the traumatic experiences, shame-based behaviors, and the dyadic process itself, and for the child to feel safe, understood and validated at a sensory-affective, pre-verbal level of experience.

According to Hughes, the primary intersubjective stance is one of acceptance and curiosity, empathy and/or playfulness, (later reduced to the acronym PACE), all the while committed to remaining emotionally engaged and available to the child. It is an active, affectively varied, dyadic interaction that interweaves moments of experience and reflection.

According to Hughes, what he describes as the 'attachment sequence of attunement, disruption, and repair' occurs frequently in an attachment-based model of therapy, just as it does in the parent-child relationship. 'Resistance' is described as a disruption in the relationship that is then co-regulated by the therapist. This involves the therapist guessing how the child feels in order to be able to empathise and express the feeling. Curiosity and acceptance are considered crucial to this process. The therapist 'co-regulates' the childs dysregulated responses to 'co-construct' a new meaning.

The ultimate aim is for the child to be able to construct a new and coherent autobiography that enables the child to be in touch with their inner feelings. "As the therapist gives expression to the child’s subjective narrative, s/he is continuously integrating the child’s nonverbal responsiveness to the dialogue, modifying it spontaneously in a manner congruent with the child’s expressions. The dialogue is likely to have more emotional meaning for the child if the therapist, periodically, speaks for the child in the first person with the child’s own words." (Hughes 2004 p18)

Role of caregiver
The active presence of one of the child’s primary caregivers is considered to greatly enhance psychological treatment that involves establishing dyadic interactions of nonverbal attunement, affective/reflective dialogue and frequent repair as such participation by the caregiver makes it easier for children to incorporate these transforming experiences into their daily lives.

It follows therefore that the affective/reflective capacities of the foster/adoptive caregiver—along with those of the therapist—must be adequately developed if children are to develop similar abilities within themselves. Hughes points out that the therapy presupposes that the therapist and parent are able to remain engaged with the children when their attachment schema are activated by the stress of the dyadic interaction and the therapeutic theme. The therapist must explore relevant past experiences of the caregivers to determine if they have the ability to remain present with the child whenever the child is at risk for affective, behavioral, and/or cognitive dysregulation. If the primary caregiver is the past abuser, it is crucial that full repsonsibility has been accepted otherwise the caregiver cannot be appropriately empathic. However Hughes considers that attachment based treatment can be undertaken with just the therapist.(Hughes 2004 p25)

Controversy
DDP has been criticised for the lack of a comprehensive manual or full case studies to provide details of the process. In addition, although non-verbal communication, communicative mismatch and repair, playful interactions and the relationship between the parents attachment status and that of a toddler are all well documented and important for early healthy emotional development, 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. It is also suggested that the therapy appears to use age regression techniques to bring about such recapitulation - a feature of attachment therapy not congruent with attachment theory.

Opinion is divided as to whether Dyadic Developmental Psychotherapy is in fact an attachment therapy. The Taskforce report places Hughes and Becker-Weidman within the attachment therapy paradigm and indeed specifically cites Becker-Weidman for, amongst other things, the use of age regression, though not for coercive or restraining practices p.79. They also describe DDP as an attachment therapy in their November 2006 Reply to Letters. Becker-Weidman had stated in his letter to the Taskforce that it was essential to treat a child at its developmental rather than chronological level, but the Taskforce in its November 2006 Reply to Letters disagreed, p382.

The Taskforce in their Reply to Letters describe Hughes as 'a leading attachment therapist' and cite Hughes (together with Kelly and Popper) as examples of attachment therapists who have more recently developed their practices away from the more concerning attachment therapy techniques, p383. Indeed they use Hughes' list of specific techniques that he believes should be or have been excluded from the practice of DDP as an example of concerning treatment behaviors.

The advocacy group Advocates for Children in Therapy include dyadic developmental psychotherapy in their list of 'attachment therapies by another name', and continue to list Hughes as a proponent of attachment therapy citing material relating to holding therapy from earlier, pre dyadic developmental psychotherapy publications in addition to Hughes more recent publications. In particular they cite material from Hughes website about the use of physical contact in therapy as follows: "To be effective, the child must be engaged by the therapist at the level of preverbal attunement rather than in a setting of rational discussions. The therapy must also involve a great deal of physical contact between the child and the therapist and parent.  During much of the most intense therapeutic work, the child is being touched or held by the therapist or parent.  His intense emotions are received, accepted, and integrated into the self.  Within a therapeutic atmosphere based on attunement, he is able to begin to explore aspects of himself and his relationships with his parents that have previously not been accessible.  The development of both the child's attachment to his parents and his integrated self is the primary goal of the therapist; all else is secondary."

According to the author of this article on dyadic developmental psychotherapy "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 creates a multi-sensory experience to facilitate attunement, emotional reciprocity and stability, enhances empathic responses, safety and re-enactment of the nurturing holding of infancy to provide a corrective cognitive-emotional experience." According to Hughes website "The child may be held at home or in therapy for the purpose of containment when the child is in a dysregulated, out-of-control state only when less active means of containment are not successful in helping him/her regain control, and only as long as the child remains in that state. The therapist/parent's primary goal is to insure that the child is safe and feels safe.  The goal is never to provoke a negative emotional response or to scold or discipline the child.  The model for this type of holding is that of a parent who holds an overtired, overstimulated, or frightened preschool child and helps him/her to regulate his distress through calm, comforting assurances and through the parent's own accepting and confident manner.".

Prior and Glaser state that Hughes therapy 'reads' as good therapy for abused and neglected children, though with 'little application of attachment theory' but do not include it in their section on attachment therapy.

Evidence
In two studies by Becker-Weidman, the second being a four year follow up of the first, dyadic developmental psychotherapy was reported to be an effective treatment for children with complex trauma who met the DSM IV criteria for Reactive attachment disorder. The first study concluded that children who received dyadic developmental psychotherapy had clinically and statistically significant improvements in their functioning as measured by the Child Behavior Checklist (Achenbach), while the children in the control group showed no change one year after treatment ended. The study also used the Randolph Attachment Disorder Questionnaire as a measure.

The treatment group comprised thirty-four subjects. This was compared to a 'usual care group' of thirty subjects. The published reports on this work do not specify the nature of "usual care" or clarify why the "usual care" group, who were assessed at Becker-Weidman's clinic, did not have treatment there. Treatment consisted of an average of twenty three sessions over eleven months. The 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. 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.

In the follow-up study the results from the original study were maintained an average of 3.9 years after treatment ended. 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.

Becker-Weidman's first (2006) study was considered by the APSAC Taskforce in their November 2006 Reply to Letters following their main report on attachment therapy. The Taskforce had in their original report criticised Dr Becker-Weidman for claiming an evidence base to his therapy, and indeed for claiming to be the only evidence based therapy, where the Taskforce considered no evidence base existed. . Dr Becker-Weidman responded to this with an open letter citing his study. The Taskforce examined the (2006) study, criticized the methodology and stated that although the study was an important first step towards learning the facts about DDP outcomes, it fell far short of the criteria that must be met before designating a treatment as evidence based.

Between the Taskforce report and Reply to Letters, Craven & Lee (2006) undertook a literature review of 18 studies of interventions used for foster children and classified them under the controversial Saunders, Berliner, & Hanson (2004) system. They considered only two therapies aimed at treating disorders of attachment, each of which was represented by a single study: dyadic developmental psychotherapy and holding therapy. They placed both in Category 3 as "supported and acceptable". This classification means that the evidence basis is weak, but that there is no evidence of harm done by the treatment. The Craven & Lee classification report has been criticized as unduly favourable (Pignotti & Mercer 2007 ) This critique noted the absence of a comprehensive manual giving details of the dyadic developmental psychotherapy intervention - one of the necessary criteria for assessment using the Saunders et al. guidelines, and one without which no outcome study can be placed in any of the available categories. Craven and Lee rebutted this paper in a reply that concentrated on holding therapy rather than dyadic developmental psychotherapy.