Dyadic Developmental Psychotherapy
DDP is a treatment approach to trauma, neglect, loss, and/or other dysregulating experiences, that is based on principles derived from Attachment Theory and Research and also incorporates aspects of treatment principles for PTSD.
DDP involves creating a safe setting in which the client can begin to explore, resolve, and integrate a wide range of memories, emotions, and current experiences, that are frightening, stressful, avoided or denied. Insuring that this exploration occurs with nonverbal attunement, reflective-non-judgmental–dialogue, along with empathy and reassurance, creates safety. As the process unfolds, the client is creating a coherent life-story, or autobiographical narrative, 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-constructing meaning.
Nonverbal attunement refers to the frequent interactions between a parent and infant, in which both are sharing affect and focused attention on each other in a way such that the child’s enjoyable experiences are amplified and his/her stressful experiences are reduced and contained. This is done through eye contact, facial expressions, gestures and movements, voice tone, timing and touch. These same early attachment experiences, which are fundamental for healthy emotional and social development, are utilized in therapy to enable to the client to rely on the therapist to regulate emotional experiences and to begin to understand these experiences more fully. Such understanding develops further through engaging in a conversation about these experiences, without judgment or criticism. The therapist will maintain a curious attitude about the memories and behaviors, encouraging the client to explore them to better understand their deeper meanings in his life and gradually develop a more coherent life-story. This process may be stressful for the client, so the therapist will frequently "take a break" from the work, provide empathy for the negative emotion that may be elicited, and reassure the client about his efforts and the therapeutic relationship.
The primary therapeutic attitude demonstrated throughout the sessions is one of Playfulness, Acceptance, Empathy and Curiosity (PACE).
For the purpose of increasing the client’s safety, his/her readiness to rely on significant attachment figures in his life, and his/her ability to resolve and integrate the dysregulating experiences that are being explored, a person who an important attachment figure to the client will be actively present. When the client is a child, this most often will be the child’s parent or guardian. When the client is an adult, this most often will be the adult’s partner.
The role of the parent in his/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.
4. Validate his/her worth in the face of trauma and shame-based behaviors.
5. Reassure him/her that your relationship remains strong regardless of the issues.
6. Help him/her to make sense of his/her life so that it is organized and congruent.
7. Help him/her to understand your perspective and motives with respect to him/her.
The parent’s role is not to criticize, lecture, nag, or amplify shame. Periodic confrontation may be necessary and needs to be integrated into the overall treatment session. Reassurance and repair of the relationship after confrontation is crucial. The child will not participate fully in therapy, and will not benefit much from the process if s/he does not feel safe in a setting primarily characterized by PACE.
When we are asking a client to address frightening or shame-based memories, emotions, and current experiences, when are asking him/her to engage in an activity that will be emotionally painful. In do so it is crucial that we maintain an attitude characterized by PACE in order to insure that the client is not alone while entering that painful experience. The client has developed significant symptoms and defenses against that pain, most often because s/he was alone in facing it. When we help to carry and contain the pain with him/her, when we co-regulate it with him/her, we are providing him/her with the safety needed to explore, resolve, and integrate the experience. We do not facilitate safety when we support a client’s avoidance of the pain, but rather when we remain emotionally present when he is addressing the pain.
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 P ACE.
2. Shame is frequently experienced when exploring many experiences of negative affect. Shame is always met with empathy, before considering interventions to question it.
3. Emotional communication that combines nonverbal attunement and reflective dialogue and is followed by relationship repair when necessary is the central therapeutic activity.
4. While supporting the reduction of shame, we also support the increase of guilt.
5. Resistance is met with PACE, rather than being criticized and/or punished.
6. Treatment is directive and client-centered. Directives are frequently modified, delayed, or set-aside in response to resistance which is met with P ACE.
Experiential: Various techniques are used that are designed to engage the child in corrective emotional experiences. Since the causes of attachment disorder occur during the child’s pre-verbal developments, experiences not words are the "active ingredient" in the healing process. A variety of therapeutic techniques (psychodrama, imagery, social skill-building, and holdings, eye contact and touch) are used to elicit and correct the child’s pathology.
Holding is one of the experiential methods used in therapy. Children are held comfortably and in a nurturing position, such as cradling, that encourages direct eye contact with the person talking to them. The therapist or parent holding the children maintains control over the child’s attempts to escape the discomfort of feeling venerable and/or shame through protest, squirming and other avoidance tactics. The purpose of holding is to create a multi-sensory experience to encourage compliance and acceptance of the therapist’s or parent’s reality, enhance attachment relationships, direct the child’s attention and enhance attachment relationships. Should the child begin to engage in behaviors that are dangerous to self or others or out-of-control then restraint is used to ensure everyone’s safety. Holding and restraining are done differently and serve separate purposes. Wrappings, re-birthing and rage deduction techniques are not used.
Regressive Work: A major dynamic in treatment is helping the child regress to the period that produced the pathology. This allows the child to access deep, genuine, and intense emotions associated with the events and people who created those feelings. The corrective experience is orchestrated to allow the child to express these feelings, recognize and recall them, and identify the events and the people involved. This experience then provides an opportunity for resolution of significant old pathological emotions while simultaneously creating powerful new bonds with trustworthy and reliable parents.
Affective Emphasis: The therapy has a major emotional or affective emphasis. Emotions have a major causative effect on behavior therefore when the emotions that cause the behavior change, the behaviors will change, often with little or no discussion. The trauma the children have experienced produces three major emotions: fear, sadness, and anger. These emotions underlie the child’s avoidance of attachment. Consequently, the regressive work that helps access fear, sadness, and anger is a process that helps heal emotional trauma(s).
Confrontive: In contrast to play therapy or talk therapy, in which the child chooses the subject matter, the therapists and parents are in charge and direct the course of therapy. Children with attachment disorder will not voluntarily face their painful emotions. Denial, avoidance, and dissociation are the defenses that allowed them to survive their trauma and they are not disposed to give them up easily. "Confrontive" means dealing directly with the heart of the child’s experience. The child is given the difficult choice of facing the consequences of not resolving problems or going through the painful work of solving them. This choice is given to the child genuinely and repeatedly but in a compassionate, understanding, and supportive manner.