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Attachment and the Impact of Early Childhood Trauma - Daniel A. Hughes, Ph.D.
All Nations Centre, Cardiff, UK - 5 November 2010
Dhughes202@comcast.net - www.Danielhughes.org
Dyadic Developmental Psychotherapy
DDP is a treatment approach to trauma, loss, and/or other dysregulating experiences, that
is based on principles derived from attachment theory and research and also incorporates
aspects of treatment principles that address trauma. It is a specialized form of
Attachment-Focused Family Therapy which is utilized for all families.
DDP involves creating a safe setting in which the child can begin to explore, resolve, and
integrate a wide range of memories, emotions, and current experiences, that are
frightening, shameful, avoided or denied. Safety is created by insuring that this
exploration occurs within an intersubjective context characterized by nonverbal
attunement, reflective dialogue, acceptance, curiosity, and empathy. As the process
unfolds, the client is creating a coherent life-story which 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-creating meaning.
Primary intersubjective experiences between a parent and infant contain shared affect
(attunement), 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,
and a congruent intention to understand the other/be understood by the other. This is
done through contingent, nonverbal (eye contact, facial expressions, gestures and
movements, voice prosody and touch) communications. These same early parent-child
experiences, fundamental for healthy emotional and social development, are utilized in
therapy to enable to the child to rely on the therapist and parents to regulate emotional
experiences and to begin to understand these experiences more fully. Such understanding
develops further through engaging in affective/reflective (a/r) dialogue about these
experiences, without judgment or criticism. The therapist will maintain a curious attitude
about past and present events and behaviors, facilitating the client’s ability 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, go slower, provide empathy for the negative
affect that may be elicited, and repair the treatment relationship.
The primary therapeutic attitude demonstrated throughout the sessions is one of
playfulness, acceptance, curiosity, and empathy (PACE).
For the purpose of increasing the child’s psychological safety, his readiness to rely on
significant attachment figures in his life, and his ability to resolve and integrate the
dysregulating experiences that are being explored, a person who is a primary attachment
figure to the client will be actively present. The role of the parent—or other attachment
figure—in her child’s psychotherapy is the following:
1. Help him to feel safe.
2. Communicate PACE, both nonverbally and verbally.
3. Help him to regulate any negative affect such as fear, shame, anger, or sadness.
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4. Validate his worth in the face of trauma, loss, and shame-based behaviors.
5. Provide attachment security regardless of the issues being explored.
6. Help him to make sense of his life so that it is organized and congruent.
7. Help him to understand the parents’ perspective and intentions toward him.
Frequently a person’s symptoms are his unsuccessful ways of regulating frightening or
shame-based memories, emotions, and current experiences. Confronting a child 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 daily structure and supervision or through applying
natural consequences for them. Again, however, the issues will be addressed more
effectively when done with PACE rather than routine anger, rejection, harsh discipline, or
other shame-inducing actions.
When we are asking a child to address frightening or shame-based memories, emotions,
and current experiences, we are asking him to engage in an activity that will be
emotionally stressful. 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 child has developed significant symptoms and defenses against that pain, most often
because he was alone in facing it. When we help to carry and contain the pain with him,
when we co-regulate the affect with him, we are providing him with the safety needed to
explore, resolve, and integrate the experience. We do not facilitate safety when we
support a child’s avoidance of the pain, but rather when we remain emotionally present
when he is addressing and experiencing the pain.
For a caregiver and therapist to remain present for a child during periods of
dysregulation, it is important for them to have resolved any similar issues from their own
attachment histories. The significant adults in the child’s treatment need to address—in
their own lives—any areas of fear or shame that are similar to what they are asking the
child to address. Individual or joint treatment for the parent(s) may be necessary prior to,
instead of, or during this family-focused treatment.
The following statements reflect routine features of DDP:
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, followed by curiosity about its development,
organization, exceptions, management, and impact on the narrative.
3. Emotional communication that combines nonverbal attunement and reflective
dialogue and is followed by relationship repair when necessary, is the central
therapeutic activity. All communication is “embodied” within the nonverbal.
4. Resistance is addressed and met with PACE, rather than being confronted.
5. Treatment is directive and client-centered. Directives are frequently modified,
delayed, or set-aside in response to the child’s response to the directive.
6. The therapist is responsible for insuring the rhythm and momentum of the session. The
therapist insures the development of a coherent story line through his matched,
regulated, affect, accepting awareness, and clear intentions.
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DEVELOPMENTAL TRAUMA DISORDER
Toward a rational diagnosis for children with complex trauma histories
Bessel van der Kolk, MD
Psychiatric Annals 35:5 May 2005, Pp.401-408
“Traumatized children rarely discuss their fears and traumas spontaneously. They also
have little insight into the relationship between what they do, what they feel, and what
has happened to them.” P.405
“The PTSD diagnosis does not capture the developmental effects of childhood trauma:
The complex disruptions of affect regulation;
The disturbed attachment patterns;
The rapid behavioral regressions and shifts in emotional states;
The loss of autonomous strivings;
The aggressive behavior against self and others;
The failure to achieve developmental competencies;
The loss of bodily regulation in the areas of sleep, food, and self-care;
The altered schemas of the world;
The anticipatory behavior and trauma expectations;
The multiple somatic problems, form gastrointestinal distress to headaches;
The apparent lack of awareness of danger and resulting self endangering behaviors;
The self-hatred and self-blame;
The chronic feelings of ineffectiveness.” P. 406
Treatment Implications “Treatment must focus on three primary areas:
1. Establishing safety and competencies. 2. Dealing with traumatic re-enactments
3. Integration and mastery of the body and mind.” P. 407
“Unless this tendency to repeat the trauma is recognized, the response of the environment
is likely to replay the original traumatizing, abusive, but familiar, relationships. Because
these children are prone to experience anything novel, including rules and other
protective interventions as punishments, they tend to regard teachers and therapists who
try to establish safety as perpetrators.” Pp.407-408.
COMPLEX TRAUMA IN CHILDREN AND ADOLESCENTS
Alexandra Cook, Joseph Spinazzola, Julian Ford, Cheryl Lanktree, et al
Psychiatric Annals, Vol. 35, Iss 5 May, 2005, pg390-398.
Domains of Impairment in Children Exposed to Complex Trauma
1. Attachment
2. Biology
3. Affect Regulation
4. Dissociation
5.Behavior Control 6.Cognition
7. Self-Concept
Six Core Components of Complex Trauma Intervention:
1. Safety 2. Self-Regulation 3. Self-Reflection 4. Traumatic Experience Integration
5. Relational Engagement
6. Positive Affect Enhancement
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ATTACHMENT-FOCUSED CARE WITH TRAUMATIZED, DISORGANIZED
CHILDREN
ATTITUDE
1.Accepting
4. Loving
2. Curious
5. Playful (PLACE)
3. Empathic
To Facilitate the CAPACITY FOR FUN AND LOVE:
1. Reciprocal Intersubjective Experiences
2. Stay physically close.
3. Integrate and resolve own issues from own attachment history.
4. Eye contact, smiles, touch, hugs, rocking, movement, food.
5. Emotional availability in times of stress
6. Safe Surprises
7. Playful, nurturing, holding your child
8. Make choices for him and structure his activities.
9. Reciprocal communication of thoughts & feelings, shared activities
10. Humor and gentle teasing
11. Basic safety and security
12. Opportunities to imitate parents
13. Spontaneous discussions of past and future
14. Routines & Rituals to develop a mutual history
To Facilitate EFFECTIVE DISCIPLINE (Shame-Reduction and Skill Development):
1. Stay physically close.
2. Make choices for him and structure his activities.
3. Set & Maintain your favored emotional tone, not your child’s
4. Accept thoughts, feelings, wishes, intentions, and perceptions of child
5. Provide natural and logical consequences for behaviors
6. Be predictable in your attitude, less predictable in your consequences
7. Reattunement following experiences he experiences as shameful
8. Interrupt cycles of resistance: “mom time”
9. Use paradoxical responses
10. Use permission, thinking, practicing, having limits, being supervised.
11. Employ quick, appropriate, anger, not habitual anger or annoyance
12. Convey with empathy that you are not overwhelmed by your child’s problem
13. Use the child’s anger to build a stronger connection
14. Reciprocal communication of thoughts and feelings
15. Be directive and firm, but also be attuned to the affect of your child
16. Greatly limit your child’s ability to hurt you, either physically or emotionally.
17. Integrate and resolve own issues from own attachment history.
Dan Hughes
dhughes202@comcast.net
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PHYSICAL PRESENCE
Once they know how to crawl, toddlers have the ability to touch, bite, pull, or climb on
everything within their reach. Parents immediately begin to socialize them, for their
safety and the safety of others as well as the protection of the family’s assets.
Maintaining Physical Presence is the primary way that parents discipline toddlers.
Parents are aware of their toddler. They “keep an eye on her” and “an ear on him”
constantly throughout the day. They are near their child, so that the child takes their
presence for granted and gradually comes to rely on their knowledge about what to do.
Their child also constantly engages in “social referencing” whereby (s)he watches her/his
parents’ nonverbal reactions to know whether or not someone or something is a danger or
is safe. The develop their primary knowledge of self, other, and the world through
relying on their parents’ minds and hearts. The parents’ presence gives the child the sense
of safety necessary to be able to explore and learn about her/his world.
Children lacking a secure attachment need physical presence just as much as does the
toddler. They do not have the skills needed to internalize rules, control impulses,
remember consequences of their actions, have empathy for others or feel safe. Allowing
them to be outside of the parents’ presence, to make the “right” choice unsupervised, is a
blueprint for disaster and failure.
Physical Presence Involves:
Structure &Containment (The following is applied to the degree that the child requires.)
1. Supervision. The parent is aware of the child at all times when (s)he is not sleeping. If
the parent is out of visual contact briefly, the child is confined to an area (with a door
alarm if necessary) where (s)he cannot hurt her/himself, others, or destroy something
important.
2. The child sits, plays, works, or rests near her/his parent. The parent enjoys her/his
company frequently with brief engagements.
3. There is a well defined routine, alternating active and quiet activities, work and play,
solitary and interactive activities
4. The parent chooses the activities, as well as much of the food, clothing, toys, etc. for
the child, giving him/her the ability to choose only when she/he shows some readiness to
be able to make choices, that lead to contentment and success.
5. The home is “child-proof”.
Fun and Love
The parent provides numerous activities to become engaged with her/his child with
reciprocal fun and love. The parent is attuned to the child’s emotional state and is
engaged with her/her in positive emotional, nonverbal communication throughout.
1. Feed, prepare food together
6. Wash, dress and comb hair.
2. Hold, rock, hug, touch, massage
7. Read and tell stories
3. On the floor: roll, crawl, rest among pillows. 8. Quiet, extended bedtime routines.
4. Songs and games for babies and toddlers.
9. Go for a walk, holding hands.
5. Habitual background music
10. Periods of “baby talk”, “small talk”.
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Dan Hughes dhughes202@comcast.net
Parenting Profile for Developing Attachment©
Respond from 1-5. 1 represents very little; 5 a great deal of the characteristic/skill.
Focus on adult’s abilities, not whether or not the child is receptive to the interaction.
My Perception My Perception of
Of Self
Spouse/Friend
____________________(1 =very little 5 =very much)__________________________
1. Able to maintain a sense of humor- - - - - - - - - - - - - _____
_____
2. Comfortable with giving physical affection- - - - - - - _____
_____
3. Comfortable receiving physical affection - - - - - - - - _____
_____
4. Ready to comfort child in distress - - - - - - - - - - - - - _____
_____
5. Able to be playful with child - - - - - - - - - - - - - - - - _____
_____
6. Ready to listen to child’s thoughts and feelings - - - - _____
_____
7. Able to be calm and relaxed much of the time.- - - - - _____
_____
8. Patient with child’s mistakes- - - - - - - - - - - - - - - - - _____
_____
9. Patient with child’s misbehaviors - - - - - - - - - - - - - _____
_____
10. Patient with child’s anger and defiance- - - - - - - - - - _____
_____
11. Patient with child’s primary two symptoms- - - - - - - _____
_____
12. Comfortable expressing love for child - - - - - - - - - - _____
_____
13. Able to show empathy for child’s distress- - - - - - - - _____
_____
14. Able to show empathy for child’s anger - - - - - - - - - _____
_____
15. Able to set limits, with empathy, not anger - - - - - - - _____
_____
16. Able to give consequence, regardless of his response- _____
_____
17. Able and willing to give child much supervision.- - - - _____
_____
18. Able and willing to give child much “mom-time”.- - - _____
_____
19. Able to express anger in a quick, to the point, manner _____
_____
20. Able to “get over it” quickly after conflict with child.- _____
_____
21. Able to allow child to accept consequence of choice. - _____
_____
22. Able to accept, though not necessarily agree with,
the thoughts and feelings of your child.- - - - - - - - _____
_____
23. Able to accept, though you may still discipline,
the behavior of your child. - - - - - - - - - - - - - - - - _____
_____
24. Able to receive support from other adults
in raising this difficult child.- - - - - - - - - - - - - - - _____
_____
25. Able to acknowledge failings and mistakes
in raising this difficult child.- - - - - - - - - - - - - - - _____
_____
26. Able to ask for help from people you trust - - - - - - - - _____
_____
27. Able to refrain from allowing your child’s
problems to become your problems.- - - - - - - - - - _____
_____
28. Able to cope with criticism from other adults
about how you raise your child.- - - - - - - - - - - - - _____
_____
29. Able to avoid experiencing shame and rage over
your failures to help your child.- - - - - - - - - - - - - _____
_____
30. Able to remain focused on the long-term goals.- - - - - _____
_____
Dan Hughes
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Questions for Parental Self-Reflection
Adapted from Siegel, D.J. & Hartzell, M. (2003).
Parenting from the inside out. New York:Jeremy P. Tarcher/Putnam.
1. What was it like growing up? Who was in your family?
2. How did you get along with your parents early in your childhood?
How did your relationship evolve throughout your youth and into the present?
3. How did your relationship with your mother and father differ? Were similar?
Are there ways in which you try to be like/not like each parent?
4. Did you feel rejected or threatened by your parents?
Where there other experiences in your life that were overwhelming/traumatic?
Are these experiences “still alive”? Continue to influence your life?
5. How did your parents discipline you? What impact did that have on your childhood?
How does it impact your role as a parent now?
6. Do you recall your earliest separations from your parents? What was it like?
Did you ever have prolonged separations from your parents?
7. Did anyone significant in your life die during your childhood or later?
What was it like for you then and how does it affect you now?
8. How did your parents communicate with you when you were happy/excited?
How did they communicate when you were unhappy/distressed?
Did your father and mother respond differently during these times? How?
9. Was there anyone besides your parents who took care of you?
What was that relationship life for you? What happened to them?
10. If you had difficult times during your childhood, were there positive relationships
in or outside your home that you could depend on? How did those connections
benefit you then and how might they help you now?
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Dan Hughes dhughes202@comcast.net
CORE ASSUMPTIONS ABOUT CERTAIN BEHAVIORS OF CHILD
Argue, complain, control, rage, withdraw, not ask for help, not show affection, bang head
to sleep, scream over routine frustrations, constant chatter, avoid eye contact, lie, steal,
gorge food, socialize indiscriminately
Under the Behavior
Conviction that only self can/will meet own needs
Never feeling safe
Pervasive sense of shame
Conviction of hopelessness and helplessness
Fear of being vulnerable/dependent
Fear of rejection
Inability to self-regulate intense affect—positive or negative.
Inability to co-regulate affect—positive or negative.
Felt sense that life is too hard. Feeling “invisible”
Assumptions that parents’ motives/intentions are negative
Lack of confidence in own abilities
Lack of confidence that parent will comfort/assist during hard times.
Inability to understand why s/he does things.
Need to deny inner life because of overwhelming affect that exists there.
Inability to express inner life even if he wanted to.
Fear of failure
Fear of trusting happiness
Routine family life is full of associations to first family
Discipline is experienced as abuse/neglect
Inability to be comforted when disciplined/hurt.
CORE ASSUMPTIONS ABOUT CERTAIN BEHAVIORS OF PARENTS
Chronic anger, harsh discipline, power struggles, not ask for help, not show affection,
difficulty sleeping, appetite problems, ignoring child, remaining isolated from child,
reacting with rage & impulsiveness, lack of empathy for child, marital conflicts,
withdrawal from relatives and friends, chronic criticism.
Under the Behavior
Desire to help child to develop well. Love and commitment for child.
Desire to be a good parent. Uncertainty about how to best meet child’s needs.
Lack of confidence in ability to meet child’s needs.
Specific failures with child associated with more pervasive doubts about self.
Pervasive sense of shame as a parent.
Conviction of helplessness and hopelessness.
Fear of being vulnerable/being hurt by child. Fear of rejection by child as a parent
Fear of failure as a parent.
Inability to understand why child does things.
Inability to understand why self reacts to child.
Association of child’s functioning with aspects of own attachment history.
Feeling lack of support and understanding from other adults.
Felt sense that life is too hard. Assumptions that child’s motives/intentions are negative.
Feeling that there are no other options besides the behavior tried.
Dan Hughes
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Shame and Guilt
Decrease the One, While Increasing the Other
DIFFERENCES
SHAME
GUILT
Focus of evaluation
Degree of distress
Phenomenological exp
Global Self
More Painful
Feel small, worthless
Powerless, shrinking
Split: observing/observed
Impair: Global Devaluation
Other’s evaluation of self
Mentally undoing part of self
Want to hide; strike back
Specific Behavior
Less Painful
Tension, remorse
Regret
Unified self intact
Minimal
Effects of behavior on other
Mentally undoing behavior
Want to confess; repair
Operation of “self”
Impact on “self”
Primary Concern
Counterfactual processes
Motivational feature
Shame correlated with less empathy; Guilt correlated with more empathy
Shame: Intense Anger, Blame Other, Avoid Devaluation of Self, Regain sense of agency
Guilt: Moderate Anger, Triggers Problem-Solving, Relationship Repair.
Empirical research “consistently demonstrates a relationship between proneness to
shame and a whole host of psychological symptoms, including depression, anxiety, eating
disorder symptoms, subclinical sociopathy, and low self-esteem.” (p.120)
Empirical research shows that guilt does not lead to psychological symptoms and is
quite adaptive.
June Price Tangney & Ronda Dearing, Shame & Guilt, (2002), NY: Guilford Press.
Dan Hughes
dhughes202@comcast.net
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Characteristics of A/R Dialogue
1. Attitude of playfulness, acceptance, curiosity and empathy. These factors
provide the momentum for the therapeutic, transforming quality of the dialogue. The
therapist actively conveys through these qualities that all memories, affective states, and
events can be accepted, understood, and integrated into the narrative. Breaks are easily
repaired and the flow within nonverbal/verbal, affect/reflection, follow/lead/follow
proceeds within a sense of safety and with an openness to the discovery of new aspects of
self and relationship. The attachment figures also use PACE. No lectures. PACE
embodies features of mindfulness and might be considered to foster intersubjective
mindfulness.
Playfulness: light, relaxed, exaggerated (affect/cognition), smile, do unexpected
Acceptance: Of thoughts/feelings/beliefs/wishes/memories/perceptions
re: behavioral events. Nonjudgmental, unconditional
Curiosity:
not-knowing, open, interested, act of discovery, surprise, “a ha”.
Empathy:
feeling-felt, joined, in the world of the other. Giving expression to
affect vitality. Compassion and loving kindness.
2. Follow-lead-follow. The therapist follows the lead of the family member, joins, is
curious, and responds. Therapist leads into related area, elaborates, wonders about
implications and follows whatever response the other gives. When necessary therapist
leads into related areas that are being avoided, while then following the client’s response
to that lead. This process parallels the parent-infant dance.
3. Connection-break-repair. In therapy, as in all relationships, there are frequent
breaks in the felt-sense of connection do to many factors. The therapist notes the breaks,
accepts them, understands them, and facilitates interactive repair. Breaks are not to be
avoided but rather are utilized for their meaning and as the source of new change
opportunities in the relationship and the self. As the b/e is normalized, given the
experience of it, the shame is reduced and the b/e is integrated into the narrative.
4. Nonverbal communication. For toddlers verbal communication flows naturally from
nonverbal communication. For all of us nonverbal communication is the primary means
we have of giving expression to our inner lives as well as to become aware of the inner
lives of others. The therapist needs to be sensitively aware of the nonverbal expressions
of family members, help to make these expressions verbal, and help to create congruence
between the nonverbal and verbal. Nonverbal expression/communication:
Matched, cross-modality vitality affect
Congruent with verbal communication
Awareness of other’s nonverbal meaning
Clear, non-ambiguous expressions
Flowing—gradual, regulated, changes
Gaze—direct, warm, open, interested, responsive
Voice—variable, responsive, relaxed, open, animated, thoughtful, alive,
empathic.
Gestures—animated, expansive, dramatic, responsive
Posture—open, moving/leaning forward
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5. Affect & Reflection: balance and integration. Meaningful dialogue contains a
blend of affect and cognition, conversation and reflection, which holds the interest of the
participants and co-creates the meanings of the narratives. All memories/experiences and
affective states including attachment histories of parent/child are included. The therapist
is aware of the affect/reflection components of the here-and-now expressions and
facilitates their balance, congruence, and integration.
Verbal expression/communication
Expression of experience of B/E
Coherent, comprehensive, succinct
Self/other balance
Blend of specific/general
Past/Present/Future
Turn-taking
Organized/focused
Balance of Affective/Reflective
6. Co-creation of new meanings through primary and secondary intersubjectivity.
For the dialogue to be effective, affect attunement, joint attention, and congruent
intentions need to be present. When not present, the break will be repaired and
communication will not continue without the intersubjective matrix. Communicating to
attachment figure intensifies affect, understanding and integration, while facilitating
security of attachment. New Meanings regarding b/e and associated thoughts/feelings
emerge.
Affect:
Interests & Joy toward objects/others/self
Fear, sadness, anger
Shame & Guilt
Response to PACE
Cognitions/Reflective abilities/content
Child—Parent/Partner—friend
Trauma
Sense of autobiographical narrative
Choices/plans/intentions/priorities
Sense of efficacy
Successes/failures
Understanding/Explanations/Patterns/General Awareness
Dan Hughes
dhughes202@comcast.net
12
AFFECTIVE/REFLECTIVE (A/R) DIALOGUE
Child: “You don’t really care!!”
____________________________
Clarify, Elaborate, Explore His Subjective Experience:
Empathy:
EMPATHY:
Associated feelings:
Associated thoughts:
Implications:
Coping strategies:
General coping:
Patterns:
Self-worth:
Ass. Experiences:
Here & Now:
I-Messages:
If you think that I don’t care, that must be hard for you!
I feel sad that you experience me as not caring.
How does it feel to be with someone you don’t think cares?
If I don’t care for you, why do you think I don’t?
What does it mean if I don’t care?
How do you handle it, talking with someone you don’t think cares?
What do you do when you think someone doesn’t care for you?
Do you have that experience with someone in your family/friend?
If you think I don’t care, does it effect what you think about
yourself?
Are there other times when you have the same thoughts about
yourself
How does it feel now talking with me when you think I don’t care.
I do care for you, but am not communicating it well or you would
sense it.
I am so glad that you told me that you think that I don’t care.
I worry that therapy won’t be of help to you if you think that I
don’t care.
Similar dialogues can occur for:
This is stupid.
I think I’m bad!
I don’t care!
I don’t want to talk about it!
You/she never lets me!
You just want me to be unhappy!
You/he is mean to me.
I don’t know.
You/she thinks I’m bad.
Just leave me alone.
You/he make me so mad!
Dhughes202@comcast.net
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British Psychological Society-Division of Clinical Psychology
Faculty for Children and Young People
Service & Practice Update, 4, 4, 26-28. December 2005
Commissioned Article:
AN ATTACHMENT-FOCUSED TREATMENT FOR FOSTER AND
ADOPTIVE FAMILIES
Daniel A. Hughes, Ph.D.
Children and youth exposed to intrafamilial abuse, neglect and loss are at risk of developing
attachment disorganization, which in turn, places them at risk for manifesting various symptoms
of psychopathology, including oppositional-defiant behaviours, aggressiveness, dissociation, as
well as anxiety and depression (Lyons-Ruth, & Jacobvitz, 1999). These children often manifest a
pervasive need to control the people and events of their daily life, as well as to avoid any area of
frustration and distress. The foster carers and adoptive parents who are committed to raising
these children and youth are often uncertain about how best to raise them. Their confusing and
conflicting behaviours frequently elicit uncertain or reactive responses from those responsible for
their care. Unresolved attachment themes from the caregivers’ own histories make it even more
difficult to interact with these children in ways that will facilitate attachment security (Dozier, et
al. 2001).
Attachment theory provides an excellent guide for developing interventions that facilitate
attachment security for these children who have seldom felt safe, who have difficulty relying on
their foster and adoptive parents, and whose patterns of avoidance and control make traditional
treatment and parenting interventions less likely to be effective.
From the safety provided by a secure attachment, the child can become engaged in the
exploration of his world. His primary way of learning about self and other, events and objects, is
through the meaning that is provided by his parents. If his parents experience him as being
lovable, enjoyable, interesting, and delightful, he experiences himself as having those qualities.
In a similar manner, the meaning of his parents as well as the objects and events of his daily life is
formed by the initiatives and responses of his parents. This process is known as intersubjectivity
and it is the primary means whereby young children come to organize their experiences and
integrate them into their narratives (Trevarthen, 2001). When children are exposed to abuse and
neglect these intersubjective experiences are sparse and overwhelmingly negative. The child
experiences the emerging sense of “self” as being shameful. He begins to show little initiative to
learn more about self since he assumes that he is “bad” and “unlovable”. In a similar manner, he
does not attempt to learn about his parents’ thoughts and feelings since his initial experiences are
that they dislike him and may intend to hurt him. His inner life—his organization of
experience—remains poorly developed, fragmented, and hidden in shame. Children who
demonstrate features of attachment disorganization in their behaviour show a parallel
disorganization of their inner experiences due to a lack of varied and welcoming intersubjective
experiences with their parents.
Dyadic Developmental Psychotherapy (DDP) is a treatment modality that is based upon
principles of attachment and intersubjectivity theories (Hughes, 2004). It has been developed
over the past 15 years through the treatment of many abused and neglected foster and adopted
18
children, and more recently in the general family treatment. An initial study of its effectiveness is
now being published (Becker-Weidman, in press).
The following represents central features of DDP:
1. Treatment is family-centred whenever possible. Central treatment goals involve facilitating
attachment security between the child and his parents or carers through the here-and-now
process of therapy, including varied intersubjective experiences during which the parents
discover and respond to positive qualities in the child while experiencing themselves as
capable parents who can have a positive impact on their child. The therapist facilitates this
intersubjective process through discovering these qualities in the child and enabling the
parents to experience them. The therapist, in a similar manner, discovers positive traits in the
parents, which enables them to become engaged with more confidence and which enables
their children to see their positive intentions and affect that they hold for their child. The
therapist is a source of both safety and intersubjective discovery for both parent and child.
During the sessions, at various times the focus is on conflict-resolution, providing comfort for
past traumas and recent stress, having joint experiences of joy and pride, as well as reflecting
on their joint activities. Throughout the therapist is a mentor and coach for all members of
the family.
Any related difficulties from the carer’s attachment history are addressed, often in sessions
where the child is not present.
2. The therapist maintains a general treatment stance—or attitude—that is similar to that of the
parent toward her child during moments of intersubjectivity. The attitude involves
playfulness, acceptance, curiosity, and empathy. Playfulness encourages experiences of
reciprocal enjoyment while focusing on interests and successes. It serves to give the family a
break from the difficult issues that are also being addressed and it facilities the child’s ability
to experience and regulate positive affective states. Acceptance creates psychological safety
by conveying that while behaviours may be evaluated, the child himself is not. The
experience of the child—his perceptions, thoughts, feelings, and intentions—are always
accepted, though the behaviour that evolves from these experiences may not be. Curiosity is
continuously being directed toward the experiences of the family members. The child’s
experience tends to be negative and fragmented. By directing non-judgmental curiosity
toward the experience, the child is likely to become open to the intersubjective experience of
self, other, and events and co-create new meanings that are more able to become integrated
into the narrative. Empathy is being directed toward the experiences that are being co-created
as they emerge in order to enable the affect to be co-regulated. With empathy, the child is
able to experience both the therapist and parents as being with him as he explores past
experiences of trauma and shame.
3. During treatment the therapist follows the child’s lead when possible and takes the lead
herself when necessary to address themes that the child works to compulsively avoid. The
therapist sets a pace in this process that respects the child’s anxiety and shame, reducing the
intensity and focus as necessary to enable the child to remain engaged in the process. The
child is not confronted about his behaviours if confrontation implies anger and judgment
about his motives. Rather difficulties in his functioning are addressed with empathy, while
accepting the child’s distress over the exploration and enabling him to remain engaged in the
process. Whenever there are breaks in the intersubjective process, these breaks are repaired
before new themes are addressed.
4. Treatment primarily focuses on providing intersubjective experiences, which are
characterized by joint affect, attention, and intentions. In doing so, the emerging
conversations are characterized by heightened nonverbal communication conveying matched
19
vitality affect. This enables the family members to “feel felt” and insures that emerging
affect is being co-regulated. The meanings of the dialogues, which emerge are carried both
nonverbally and verbally. All verbal expressions are made within the context of acceptance,
curiosity, playfulness and/or empathy.
5. Being intersubjective, the treatments sessions have an impact on the family members and also
the therapist. The therapist does not maintain a detached, neutral stance but rather becomes
affectively and reflectively engaged with each family member and with the family as a whole.
As the family members experience the impact that they are having on the therapist, their
sense of self-efficacy is enhanced. They have more confidence in their abilities to be engaged
in meaningful, reciprocal relationships with the other members of the family.
6. Treatment goals involve the development and integration of both affective and reflective
abilities. These two central aspects of experience are both engaged, deepen and become more
comprehensive and coherent as they permeate the narrative of each one in the family.
7. Parenting recommendations are congruent with the moment-to-moment process of therapy.
Parents are encouraged to manifest the same playful, accepting, curious, and empathic
attitude that is characteristic of treatment. Parents are given specific suggestions for
interventions that are consistent with the treatment gains. The core parenting interventions
involve providing safety, structure, supervision, and success. Interventions are not punitive,
nor are they based on the primacy of obedience.
DDP is a model of treatment that is consistent with theories of attachment and intersubjectivity.
It does not involve any use of coercive holding, dysregulating confrontations, or emphasis on
obedience. It contains many features of more traditional relationship-based treatments that have
been present for decades and which are considered to be empirically sound (Kirschenbaum &
Johnson, 2005). Attachment security and intersubjective experiences are core features of stable
family relationship and their development are crucial if abused and neglected children and youth
are to be able to begin a new life within their new families. Through facilitating these
experiences and strengthening the functioning of the family the therapist will be able to
encourage attachment security for the child and enable him to pursue his optimal development.
References:
Becker-Weidmand, A. (2005) Treatment for children with trauma-attachment Disorders: Dyadic
Developmental Psychotherapy. Child and adolescent social work journal. December.
Dozier, M., Stovall, K.C., Albus, K.E., & Bates, B. (2001) Attachment for infants in foster care: the role of
caregiver state of mind. In Child Development, 72, 1467-1477.
Hughes, D. (2004) An Attachment-based treatment of maltreated children and young people. Attachment &
Human Development, 6, 263-278
Kirschenbaum, H. & Jourdan, A. (2005) The current status of Carl Rogers and the person-centered
approach. Psychotherapy: theory, research, practice, training. 42, 37-51.
Lyons-Ruth, K., & Jacobvitz, D. (1999) Attachment disorganization: unresolved loss, relational violence,
and lapses in behavioral and attentional strategies. In Cassidy, J. & Shaver, P.(Eds). Handbook
of Attachment. New York: Guilford Press.
Trevarthen, C. (2001) Intrinsic motives for companionship in understanding: their origin, development, and
significance for infant mental health. Infant Mental health journal, 22, 95-131.