Presentation on theme: "Exploring Dyadic Developmental Psychotherapy Attachment focused therapy for children experiencing difficulties feeling secure with caregivers Kim S. Golding."— Presentation transcript:
Exploring Dyadic Developmental Psychotherapy Attachment focused therapy for children experiencing difficulties feeling secure with caregivers Kim S. Golding
Attachment Experience and The Life Path Attachment focussed therapies are an exploration of early experience on the life path. We are not pre-determined by early experience, but an outcome of long-term cumulative development of genetic/environmental interactions and transactions. Early experience impacts on how we process experience, makes some consequences more likely, environmental continuities. If reinforced effects of early experience will be strengthened. Therefore can get ‘locked-in’ to life paths, (see Clarke & Clarke, 2000). Attachment focussed therapies aim to prevent these ‘locked-in’ life paths.
The Life Path as a Tree At conception large range of pathways we might travel on. Chosen path = interaction between child and environment. Change can shift child onto different pathway. Over time number of available pathways diminish. Therapy can help child move on to a more positive pathway. (See Bowlby, 1988/1998).
Attachment-focused Therapies Aim to guide the child or young person onto a more favourable developmental pathway by: Enhancing their experience of intersubjectivity through a more secure attachment. Using this to: Recover from developmental trauma. Overcome shame-based difficulties.
Attachment-focused Therapies So that the child is more able to: Trust relationships (reduce excessive help-seeking and dependency or reduce social isolation and disengagement). Manage stress (able to focus attention and control arousal). Regulate emotion and develop reflective skills.
Evidence Base Clinical Study of foster or adoptive children (Becker- Weidmann, 2006a, b). Treatment group (DDP) N=34, comparison group (intervention as usual) N=30. Onset of intervention no significant difference between groups (Child behaviour checklist, CBCL). One year post treatment DDP group demonstrated significant improvements on 7 categories of CBCL whilst comparison group demonstrated no improvements. Four years post treatment these improvements maintained for DDP group, whilst comparison group had worsened or stayed the same.
Theoretical Base With a limited evidence base it is important for ethical practice that the intervention is robustly based upon theoretical principles. Three theoretical areas are very relevant: –Attachment Theory. –Intersubjectivity. –Trauma.
Theoretical Principles: Attachment Theory
“Psychotherapy based on attachment theory and research actively facilitates the experience of safety that is necessary if the child is to remain engaged in exploring and resolving experiences of terror and shame.” (Dan Hughes, 2004).
“I am using attachment to mean a pattern of behaviour which is care-seeking and care-eliciting from an individual who feels they are less capable of dealing with the world than the person to whom they are seeking care.” (Bowlby, 1988/1998). Development of relationships in order to feel safe. Feeling safe is foundation for child development allowing exploration and learning involving integrated brain functioning. “Security of attachment leads to an expanded range of exploration…. Fear constricts, safety expands the range of exploration.” (Fosha, 2003).
Bowlby’s Model for Intervention Provide a secure base, facilitating exploration. Provide support, encouragement, sympathy & guidance – enhance developmental pathway. Facilitate development of healthy relationships. Facilitate positive expectations of attachment figure. Understand past – consider ideas and feelings about parents that have been unimaginable and unthinkable. “By these means the therapist hopes to enable his patient to cease being a slave to old and unconscious stereotypes and to feel, to think, and to act in new ways.” (Bowlby, 1988/1998).
The Therapist Encourage exploration of thoughts, feelings & actions. Be empathic, reliable, attentive, sympathetic and sensitively responsive. See and feel the world through the other’s eyes. Offer acceptance and respect of other. View current behaviour & beliefs as the not unreasonable products of what has been told or experienced in the past. Focus on interactions in here and now. Explore past to throw light on current feelings & behaviour. Provide the conditions in which self-healing can take place.
Barriers To Change Lack of trust because of past experience leads to: Anxiety, distrust, criticism, anger and contempt – “fighting old battles”. Or. Attention and sympathy leads to unrealistic expectation of all the care and affection that has been yearned for but not received in past. “…Whenever a therapist is puzzled by, or resentful of, the way he is being treated by a patient, he is always wise to enquire when and from whom the patient may have learned that way of treating other people. More often than not it is from one of his parents.” (Bowlby, 1988/1998).
Those who cannot remember the past are condemned to repeat it. Santayana. The Life of Reason, vol1, Scribner 1905 “When you feel you know the future you can be sure that your are reliving the past….because nobody knows the future.” (Annie Rogers, A Shining Affliction,Penguin, 1993)
Theoretical Principles: Intersubjectivity
Intersubjectivity. Joint attention = learn to regulate attention, when lacking risk of attentional difficulties (ADHD/ADD). Joint affect = learn to regulate emotion, when lacking increases risk of mood disorders (anxiety/depression); and risk of difficulties with dissociation and dysregulation. Joint intention = learn to engage in co- operative behaviour, when lacking increases risk of oppositional behaviour (ODD).
“When the infant and young child begins to explore her world, her first interest is the interpersonal world. A central characteristic of such exploration – optimised in circumstances of attachment security – involves primary and secondary intersubjectivity.” (Dan Hughes, 2006).
Primary Intersubjectivity Infant and parent discover each other in a reciprocal relationship. In the process discover more about themselves. The child develops a sense of self, reflected in the response to her from the parents. (See Trevarthen, 2001).
Secondary Intersubjectivity Child learns about world of people, events and objects. Child and parent together focus attention outwards. Shared attention helps them to explore the world and learn about the impact on each other. Child learns about the world though the meaning parent gives. Helps child develop the capacity to think. The world, self and others makes sense. Child learns to reflect upon, process and learn from experience. (See Trevarthen, 2001).
Children who experience neglect lack early intersubjective experience. They feel not special and not loveable. Children who experience anger, fear or rejection experience terror and shame. They learn to avoid intersubjective experience. Living with alternative parents – child continues to avoid intersubjective experience. This impacts on carer’s beliefs about self as a parent leading to a sense of failure, feel unsafe with child. Carer also withdraws from intersubjective experience.
Therapy The focus of therapy is to help both child and parent feel safe enough to enter into an intersubjective experience. “More than anything else, the child needs his parent to assist him in discovering who he is and who he can become.” (Dan Hughes, 2006).
Theoretical Principles Trauma
Developmental or Complex Trauma The majority of children referred for an attachment-focussed intervention will have been exposed to multiple traumatic events impacting on immediate and long-term outcomes (complex trauma, see Briere & Scott, 2006). This is also described as developmental trauma, defined as exposure to multiple or chronic interpersonal trauma, with early onset, impacting upon development. (See Cook et al, 2005; van der Kolk, 2005).
Neurosequential Model Based on neurodevelopmental principles: The brain is organized hierarchically, sensory input first enters the lower parts of the brain. Brain development occurs in a use-dependent fashion. The brain develops sequentially. The brain develops most rapidly early in life. Neural systems can be changed, some more easily than others. The human brain is designed for a different world. (See Perry, 2006).
Self-Trauma Model Emotional processing occurs when exposed to trauma-reminiscent stimuli: 1. Triggers associated implicit and/or explicit memories. 2. Activates emotional and cognitive responses ‘hooked’ to these memories. 3. But responses not reinforced by current environment. 4. Or counterconditioned by opposite emotional experience. 5. Leading to extinction of original memory- emotion/cognition association. (Briere & Scott, 2006).
Self-Trauma Model This model predicts that traumatized individuals will re-experience traumatic events (eg via flashbacks, re-enactments) in conditions of safety as part of self- healing. But the experience is titrated through effortful avoidance so that it is not overwhelming.
Intervention principles derived from trauma literature Children need to experience safety and relationships that are different from original relationships. Children need opportunities for new experiences than can over time reduce the associations that have been built around the trauma. These corrective experiences need to be consistent, predictable, patterned and frequent.
Intervention principles derived from trauma literature Interventions need to take into account where the child is on the arousal continuum – may need to help children to be physiologically regulated. Help children to develop improved affect regulation abilities. Provide titrated exposure to traumatic memories. Provide emotional and cognitive processing leading to development of coherent narrative.
Dyadic Developmental Psychotherapy (Dan Hughes) Therapist and carer work together with the child. Playful, Accepting, Curious, Empathic. Creates an environment that facilitates healthy relationship development. Offers increased sensitivity, availability and responsiveness. Co-regulates emotion and co-constructs meaning. Builds trust. Facilitates intersubjective experience and secure attachment. Contains anxiety and supports exploration.
The Therapist Is directive – determines pace, themes, activities, and techniques – modified by ongoing attunement with the child’s responses to the interventions. Provides recurring sequences of attachment – affective union, separation and reunion experiences for the child, thus facilitating intersubjective experience between parent and child.
The Therapist Maintains and models “The Attitude”: Playful. Acceptance. Curious. Empathic.
The Therapist Focus on experience related to themes of attachment, abuse and neglect. Dependency, comforting, affection, reciprocal enjoyment. Ambivalence associated with attachment emotions and behaviours. Fear of abandonment, rejection, isolation, abuse. Sense of being worthless and bad. Despair over being unwanted, unloved. Shame/rage associated with above emotional experiences.
The Therapist and Carer Relationship-centred. Therapist facilitates relationship between child and carer. Therapist and carer continually communicate emotionally with the child. Help child to be more aware of inner life of thought, affect, wishes and intentions as well as traumatic memories.
The Carer Present and actively involved. Provides affective attunement. Enters into intersubjective experience with child. Experiences mutual enjoyment with child. Demonstrates differences from abusing adults. Participates in developing joint plans and strategies for therapy. May need to explore own attachment history.
Techniques Orchestrate parent-child emotional communication: Speak for child to parent/to therapist/to abusive-neglecting parent. Direct child to express emotional experience to parent, in therapist’s words/in own words. Encourage parent to engage in reciprocal emotional communication. Help child to tolerate comfort to support expression of shame, rage, fear, sadness.
Techniques Use variety of therapeutic approaches to support the therapy. For example: Psychodrama. Narratives. Puppets, soft toys, books. Visualizations. Massage, movement, music, food. Relationship based play.
PACE An attitude that the therapist and parent hold, which will help them to maintain emotional engagement with the child. Stay curious (C)about why – less likely to feel cross or frustrated. Non- judgemental and therefore help child to be open to intersubjective experience of self, others and events.
PACE Curiosity leads to understanding, which increases acceptance (A) of child, his internal experience and reasons for his behaviour. Creates psychological safety. Provide the child with empathy (E) and support. Child experiences therapist and parents as with him as he explores past and current experience.
PACE A playful (P) stance can diffuse a situation and help the child to stay with the intersubjective experience. “Intersubjectivity is primarily a here-and- now, you-and-me experience in which both are sharing joint attention as well as similar affect, intention and meaning.” (Dan Hughes, 2004).
Co-regulation of Emotion Development of affective abilities. Child’s affective response to the experience is being co-regulated by the therapist’s affective response. As the therapist responds to the child’s affective states, nonverbally and verbally, they mark the affect with an empathic, congruent response. This helps the child to create a secondary representation of the original affect and leads to the capacity for reflective thought (see Fonagy et al 2002).
Co-construction of Meaning Development of reflective abilities. The child’s attention is being held by the therapist’s attentive stance. The therapist also provides words so that the child can gradually identify and more fully express his inner life. Through the intersubjective process the child is able to co-construct the meaning of his experience. He integrates the meanings given to the experience through the interwoven perspectives of therapist, parent and self.
Parenting to Support DDP
Attachment state of mind of carer is important for ultimate security of foster child. Carers with autonomous state of mind more likely to care for children demonstrating secure behaviour. Therefore parent’s attachment history is an important component of DDP. A carer will avoid intersubjective connection with her child if this leads to beliefs that she is failing as a parent and/or if it activates unresolved experiences from her attachment history. Carers need to be able to reflect upon their experience and to have resolved difficult experience –make sense of experience, the impact on them and have reached acceptance of this.
Understanding and Managing Shame DDP actively facilitates the experience of safety necessary for child to remain engaged in exploring and resolving experiences of shame.
Understanding and Managing Shame Shame is an affect, a complex emotion that develops later than the development of more straightforward feelings or emotions such as anger, joy or sadness. Shame is uncomfortable for children who learn to limit shame-inducing behaviours as part of the socialisation process. Shame is protective, it helps children to learn socially acceptable behaviour and thus to be able to develop relationships. This experience of shame is integrative.
Child behaves inappropriately Eg pulls dog by tail. Parent provides boundary “You mustn’t hurt the dog.” Child experiences SHAME Goes quiet, looks away, makes self smaller, hides self. Parent reassures child “It’s not you, this is about behaviour.” “It’s not our relationship, I am teaching you appropriate behaviour.” Child notices effects of behaviour on others. Feels GUILT for hurting another. Development of EMPATHY
Shame and Guilt Parent supports child and shame reduces. Child experiences feelings of guilt, but this is about my behaviour not me. Child looks outward: How does the other person feel? Child accepts responsibility and feels sorry. Motivated to make amends. = Freedom to learn from mistakes.
When Shame grows big Child is unsupported, shame gets bigger. Child experiences feelings about self, looks inward. ‘I am bad, worthless, stupid.’ Denies shame, stops feeling it. Cannot think about other person, accept responsibility or feel sorry. Does not develop feelings of guilt, not able to make amends. Does not develop empathy. Child defends against these feelings of shame – lies, blames, minimizes and rages. May internalise the feelings through self- chastisement and self-harming behaviours.
When Shame is Disintegrative Children do not experience attunement-shame-re- attunement cycle but instead they experience unregulated shame that overwhelms them. Many experiences of disintegrative shame leads to shame becoming part of core-identity. ‘I am a shameful person’, leads to chronic anger and controlling behaviours. Children need appropriately graded doses of shame and support and reassurance to help them manage this, or the shame engulfs them. Children feel alienated and defeated, never quite good enough to belong. Trapped in shame, abandoned. Shame becomes toxic. Children experience difficulty regulating emotion and thinking rationally. Unable to respond flexibly or to control impulses.
Shame and Guilt in DDP Shame is differentiated from guilt, although in some theoretical perspectives these terms are used interchangeably (eg Kaufman. 1996). Healthy guilt is seen as following on from shame in the development of conscience, resulting in social learning and appropriate remorse. Feelings of guilt, triggered by shame, leads us to regret and sorrow for our poor choices, informing our core beliefs and values.
Shame and Guilt in DDP A core aim of DDP is to enable children to move from overwhelming shame and associated negative self-evaluations (‘I am bad, you will not love me’) into healthy guilt. Children can then view misdemeanours as events which can be learnt from, rather than as disastrous and irreparable. Healthy guilt and remorse is an ordinary feature of relationships which sustain and provide ongoing love and care. It is this understanding which DDP aims to convey to children.
The Therapist Pervasive shame is a barrier to engaging in therapeutic process. Therapist uses empathy and curiosity, accepting child’s resistance and helping him to stay engaged. As therapist accepts and is curious about the child without being judgemental, including shame of his past, a new non-shame based meaning is co- constructed. When the child dysregulates the therapist remains regulated, using acceptance and empathy to co- regulate the intense affect, and to co-construct new meaning, reducing the shame of this experience.
The Carer Fear triggers attachment behaviours, but shame will inhibit this. The therapy works with the carer to help child stop hiding from attachment figure and to begin to trust and elicit care from her. The child experiences the carer’s empathy, curiosity, acceptance and playfulness about the full range of experiences explored. This helps the child to take the shame- reducing therapeutic experience into his daily life.
References Becker-Weidman, A. (2006a). Treatment for children with trauma-attachment disorders: Dyadic Developmental Psychotherapy. Child and Adolescent Social Work Journal, March, Becker-Weidman, A. (2006b). Dyadic Developmental Psychotherapy: a multi-year follow-up. In New Developments in Child Abuse Research. S.M. Sturt, Ed. Nova Science Publishers. Bowlby J (1988/1998) A secure base. Clinical applications of attachment theory. London:Routledge. Briere, J, N. & Scott C. (2006) Principles of trauma therapy: A guide to symptoms, evaluation and treatment. Sage Publications.
References Clarke A & Clarke A (2000) Early Experience and The Life Path. JKP. Cook, A Spinazzola, J. et al (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390 – 395. Fonagy P;Gergely G; Jurist E.L & Target M (2002) Affect regulation,mentalization, and the development of the self. NY: Other Press. Fosha, D. (2003) Dyadic regulation and experiential work with emotion and relatedness in trauma and disorganized attachment. In Soloman& Siegel Chapter 6. p
References Golding, K. S. (2008) Nurturing Attachments. Supporting children who are fostered or adopted. London: Jessica Kingsley Publishers. Hughes D. A. (2004) An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 6,3, Hughes D.A (2006) Building the bonds of attachment. Awakening love in deeply troubled children. Aronson,.2nd Edition. Hughes D. A. (2007) Attachment-Focused Family Therapy. W.W. Norton & Co. Ltd. Kaufman G (1996) The Psychology of Shame. Theory and treatment of shame-based syndromes. NY: SpringerPublCo. 2nded. (1sted: 1989).
References Perry, B. D. (2006) Applying principles of neurodevelopment to clinical work with maltreated and traumatized children. The neurosequential model of therapeutics. In Webb, N. B. (ed) Working with traumatized youth in child welfare. Chapter 3, Pp NY: The 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, van der Kolk (2005) Developmental trauma disorder. Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 5, 401 –408.