Dyadic Developmental Psychotherapy Essential Practices

and Methods

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 Contents

Foreword by Daniel A. Hughes

Acknowledgments
Chapter 1 Introduction
Chapter 2 First Things First
Chapter 3 A Trauma and Attachment Perspective
Chapter 4 Components of Dyadic Developmental Psychotherapy
Chapter 5 Phases
Chapter 6 Primacy of Parents
Chapter 7 Parents are the Keystone
Chapter 8 Conclusion and Summary
References
Index
About the Authors
 Foreword

Dyadic Developmental Psychotherapy (DDP) is a model of psychological

treatment that is based on principles that derive from attachment theory and
research. The goal of these principles is to facilitate the development of the
attachment relationship between a child and his parent or caregiver, while
resolving any trauma or loss that had impaired such development. DDP is
similar to many models of psychotherapy in that it is grounded in the
therapeutic relationship, including the experience of empathy, which is
probably the therapeutic factor that has the greatest “evidence-base” of all
the factors that have been studied. Where DDP may differ from many
“relationship-based” models of psychotherapy is its specific emphasis on
the attachment relationship for its organizing principle. In DDP the therapist
is clear—not ambiguous—about the impact that the client is having on the
therapist. In DDP the therapist is actively engaged in experiencing and
communicating to his clients the impact that they are having on him. The
therapist is actively discovering strengths and vulnerabilities of the client
that lie under the client’s behaviors (or symptoms) and in so doing enabling
the client to discover these same qualities. In DDP the therapist is creating
safety for the client through his consistency, predictability, and boundaries,
as well as his active expression of the attitude of PACE (Playful, Accepting,
Curious, and Empathic).
All of these features are also central in the infant or older child’s
attachment security that develops with his parent or caregiver. While DDP
strives to have the client experience the therapist’s active presence in a
manner similar to how a child experiences the presence of the child’s parent
or caregiver, even more importantly, DDP strives to develop the child-
parent relationship along the same principles. For this reason, DDP is
primarily a model of family therapy, not individual therapy. The DDP
therapist chooses the individual treatment modality only when the child or
adolescent does not live with a caregiver who is committed and able to
become a source of attachment security for the child or adolescent.
This book, Dyadic Developmental Psychotherapy: Essential Practices
and Methods by Dr. Arthur Becker-Weidman represents one more
contribution that he has made to the development of DDP. Becker-
Weidman’s research studies serve as important building blocks to the
knowledge base that is crucial to the development of a new model of
psychotherapy. Other empirical or experimental clinical practice research is
occurring in the United States and United Kingdom with the hope that it
will serve as the foundation for larger, university-based research in the
years ahead. Becker-Weidman and Deborah Shell have co-edited two
important books on DDP as it is being applied to treatment and parenting
interventions by a number of clinicians trained in this treatment model.
Finally, Becker-Weidman has played a central role in the development of
Dyadic Developmental Psychotherapy Institute (DDPI), which has
established and maintains principles for insuring that DDP is practiced in a
manner that represents a valid and reliable application of its core principles
and interventions. DDPI offers a certification process for clinicians who
want to participate in the DDP community as therapists, consultants, and
trainers.
In Dyadic Developmental Psychotherapy: Essential Practices and
Methods, Becker-Weidman provides many clinical examples of his
application of DDP with a variety of clients. These examples are rich in
therapeutic dialogue that is crucial if clinicians are to truly understand the
heart of DDP. The DDP therapist assumes a clear and active stance to insure
that affective-reflective dialogue occurs throughout the session and the
treatment process as a whole, believing that such dialogue facilitates the
attachment relationship and the development of a coherent autobiographical
narrative. Children who have experienced developmental trauma and
attachment disorganization have great difficulty initiating and maintaining
such dialogues, which in turns makes it difficult for them to become
successfully engaged in and to benefit from psychotherapy. The DDP
therapist leads the child and his parents into such dialogues, insuring that
the child’s narrative will be explored with PACE and that the intersubjective
experience and exploration will lead to the co-creation of new, integrated
meanings for the past traumatic events.
Dyadic Developmental Psychotherapy: Essential Practices and
Methods highlights Becker-Weidman’s perspective on sequential phases
(developing and maintaining the alliance, exploration, integration, and
healing) within DDP treatment. It is important for the reader to remember
Becker-Weidman’s following comment: “These phases are presented in a
discrete manner for pedagogic purposes here. In practice, the phases
overlap and the therapist and family move through treatment, and circle
back and forth among the states even within one session.”
DDP is grounded in the subjective and intersubjective experience of the
therapist and client(s) within the treatment sessions. DDP interventions
facilitate clarifying, deepening, and integrating such experiences into a
coherent narrative. It is crucial that our efforts to organize such experiences
conceptually facilitate this experiential process rather than distort it through
making the experience fit the conceptual model. Therapists might reflect on
Becker-Weidman’s emphasis on sequential phases with respect to whether it
brings additional clarity and organization to their own experience of DDP.
Also, these phases are similar to those presented in trauma-focused
therapies. It is important for the DDP clinician to remember that there are
various important differences between DDP and those therapies, even
though we might be using the same terms. For example, in DDP the
therapist—utilizing principles of attachment and intersubjectivity—is likely
to be able to develop and maintain the therapeutic alliance with all members
of the family more quickly and deeply than is the more traditional therapist
who adopts a more neutral stance and is ambiguous regarding the impact
that the family members are having on the therapist.
Becker-Weidman describes the importance of the parent or caregiver’s
commitment to the child if he or she is to serve as an attachment figure for
their child in the process of developing safety, healing, and a coherent
narrative. He makes the reader aware of the important research of Mary
Dozier with regard to the commitment of the foster parent if the child is to
truly benefit from a foster placement. The DDP therapist needs to assess the
parent or caregiver’s level of commitment before asking the child to rely
more fully upon that relationship. If the DDP therapist encourages the child
to rely on a commitment that is not present, the therapy will only produce
another traumatic experience for the child.
I believe that this work, along with the other two books co-edited by
Arthur Becker-Weidman and Deborah Shell, will assist therapists in
understanding DDP from the perspectives of other therapists experienced in
DDP. At the same time, this work will hopefully encourage therapists to
further develop their own perspectives which they may share within the
safety and intersubjective exploration that exists within the DDP
community. Dyadic Developmental Psychotherapy is a method of treatment
that is grounded in the subjective and intersubjective experiences of the
therapist and client. All of us practicing this attachment-focused form of
treatment must reflect upon these experiences in order to better understand
and develop and communicate them to others. I believe that Becker-
Weidman’s work will definitely stand with contributions of other DDP
therapists in the years to come in insuring the place of DDP within the
therapeutic community, and especially that part of the community that is
influenced by attachment theory and research.
Daniel A. Hughes
 Acknowledgments

There are a number of people whose guidance, help, and support helped
make this book possible.
Dan Hughes has been wonderfully encouraging as I tried to write about
his treatment. I value Dan’s opinions and thinking. I enjoyed writing an
article (Becker-Weidman & Hughes, 2008) with him a few years ago and
have always learned from his insights. I consider Dan a friend and a mentor.
Dan’s support and teaching have been a source of enormous professional
growth for me, which is reflected in this book.
My friends and colleagues, Deb Shell and Robert Spottswood, have
been a source of help and guidance in this process. I always knew I could
turn to them to better understand difficult experiences and that I could count
on them for sound advice and guidance.
There were a number of board members of the Dyadic Developmental
Psychotherapy Institute and fellow certified Dyadic Developmental Psycho-
therapy therapists whose comments on the Dyadic Developmental
Psychotherapy Institute’s listserv helped me clarify and sharpen my
thinking. Their time and contributions made this a better text.
Jeanne Koch, who was an intern at the Center for Family Development
while I was working on this book, transcribed many of the clinical
examples in this book from my extensive collection of training DVDs.
Thanks to her, this book is rich in clinical examples that illustrate various
components, stages, and principles of Dyadic Developmental
Psychotherapy.
 A NOTE ON THE TRANSCRIPTS

While the transcripts and dialogues presented in this book are based on
actual client sessions, all names and identifying information has been
altered so that the identities of the people have been disguised and their
anonymity and confidentiality preserved. All transcripts are from DVD
recorded treatment sessions for which client informed consent and
permission to use the sessions for training purposes have been obtained.
The material has been altered in accordance with the American
Psychological Association’s standards regarding publication.
 Chapter 1

Introduction

Dyadic Developmental Psychotherapy is an effective, evidence-based, and

empirically validated treatment. The development of Dyadic Developmental
Psychotherapy is described in detail by its originator, Dr. Daniel Hughes
(2005/2008). Hughes developed this model over several years, beginning in
the late 1980s. Hughes continues to develop the model, including the
expansion of the model from the treatment of abused and neglected children
in foster and adoptive homes to a comprehensive model of family treatment
(Hughes, 2007, in press). Dyadic Developmental Psychotherapy continues
to evolve as research, described below, and clinical practice have led the
way toward a richer and deeper understanding of the factors that help
families and children. As the creator of this model, Hughes has written
several texts that describe this model (Hughes, 2004; Hughes, 2006;
Hughes, 2007; Hughes, in press). These texts present Dyadic
Developmental Psychotherapy as a model for treatment that is firmly
grounded in shared experiences and the healing power of emotions within
the therapeutic setting. The model has now been extended by Hughes and is
also described as Attachment Focused Family Therapy because of its broad
applicability to a variety of settings and for a variety of clients, (Hughes
2007). Dyadic Developmental Psychotherapy can be thought of as the
application of this approach to families where disorders of attachment and
trauma are central difficulties.
As I was writing up the results of my second follow-up study
demonstrating the effectiveness of Dyadic Developmental Psychotherapy
four years after treatment ended (Becker-Weidman, 2006b), I began
thinking about developing a comprehensive guide to the practice,
principles, and application of Dyadic Developmental Psychotherapy as
most easily presented to those interested in learning about this approach and
for current practitioners. I continued to think about this as I expanded my
training of therapists in a Master Class offered regularly in the United States
and overseas. Hughes has written a workbook (Hughes, in press) that will
function as a core text for those taking workshops and training that can lead
to certification as a Dyadic Developmental Psychotherapist by the Dyadic
Developmental Psychotherapy Institute. It occurred to me that while there
were a number of good texts about Dyadic Developmental Psychotherapy
(Becker-Weidman & Shell, 2005/2008; Hughes, 2006; Hughes 2007;
Hughes, in press), a detailed exposition of the approach would complement
those texts if it were to describe the major components of Dyadic
Developmental Psychotherapy and how those components are integrated
and used differently within various phases of treatment and with different
types of families. While the concept of phase is not intrinsic or inherent to
Dyadic Developmental Psychotherapy, the participants of my classes have
found the phase concept to be a useful construct in thinking about this
approach. This book is intended to provide students and practitioners of
Dyadic Developmental Psychotherapy, from beginners to those certified as
a Dyadic Developmental Psychotherapy therapist, consultant, or trainer, a
detailed guide to the practice of Dyadic Developmental Psychotherapy. In
addition, it is hoped that this book will increase consistency in the
application of the model by individuals who are using Dyadic
Developmental Psychotherapy in their practice and for research. In some
ways this book is an adjunct or support to the work of the Dyadic
Developmental Psychotherapy Institute, which was founded in 2008, to
ensure continued integrity to the model of treatment developed by Hughes.
Integrity in the application of the model facilitates reliability of delivery
across a spectrum of practitioners and facilitates the highest quality
research.
After absorbing the material in this book the reader should have a clear
understanding of the practice of Dyadic Developmental Psychotherapy, and
how one can practically use it. Advanced clinicians will find this useful to
develop a more focused understanding of the work. Therapists, parents,
residential treatment staff, social workers, psychologists, child welfare
workers, and many others should also find this book useful. It will provide
them with a deeper understanding of the practice of Dyadic Developmental
Psychotherapy and, as a treatment manual, with as explicit a road map as I
can define, given the need to be acutely responsive to the inner life of the
clients in the room in the moment. The practice of Dyadic Developmental
Psychotherapy is both art and science. The use of self is central to this
approach, and one should be able to implement Dyadic Developmental
Psychotherapy in a manner consistent with individual personality, history,
and pattern of attachment; that is the art. This book will attempt to provide a
framework for using one’s self therapeutically within the context of Dyadic
Developmental Psychotherapy; that is the science.

RESEARCH BASE

Dyadic Developmental Psychotherapy is an effective, evidence-based

(Craven & Lee, 2006) and empirically validated treatment. Craven & Lee
(2006) determined that Dyadic Developmental Psychotherapy is a
supported and acceptable treatment (category 3 in a six-level system).
However, their review was only based on results from a partial preliminary
presentation of an ongoing follow-up study, subsequently completed and
published in 2006. This study compared the results of Dyadic
Developmental Psychotherapy with other forms of treatment, “usual care,”
one year after treatment ended. A second study extended these results to
four years after treatment ended. Based on the Craven & Lee classifications
(Saunders et al. 2004), inclusion of those studies would have resulted in
Dyadic Developmental Psychotherapy being classified as an evidence-
based category 2, “Supported and probably efficacious.” Since the
development of Dyadic Developmental Psychotherapy, there have been two
empirical studies demonstrating the effectiveness of Dyadic Developmental
Psychotherapy published by this author (Becker-Weidman, 2006a, Becker-
Weidman, 2006b). These two studies each had a sample size of 64.
The first study (Becker-Weidman, 2006a) compared two groups of
children who met the criteria for Reactive Attachment Disorder and
Complex Trauma. The experimental group received Dyadic Developmental
Psychotherapy at The Center for Family Development, while the control
group received other standardized treatments by other qualified
professionals at other clinics. The two groups were matched and were not
significantly different on a variety of variables including age, gender, length
of time in placement or adoption, and their pre-treatment scores on the
Child Behavior Checklist (CBCL) (Ackenbach, 1991) and various other
demographic variables. Both groups of children had scores in the clinical
range on the CBCL before treatment. One year after treatment ended, the
children in the experimental group (Dyadic Developmental Psychotherapy
treatment) had post-test scores on all scales of the CBCL that were in the
normal range and that were statistically significantly different from their
pre-test scores. The children in the control group had post-test scores that
remained in the clinical range and there were not statistically significantly
different from their pre-test scores.
The second study (Becker-Weidman, 2006b) followed the children for
four years after treatment ended. This study found that the children who had
received Dyadic Developmental Psychotherapy continued to have CBCL
scores in the normal range, remaining statistically significantly lower than
their pre-test CBCL scores. Children in the experimental group, who
actually continued to receive other treatment from other providers, not only
had CBCL scores that remained in the clinical range, but on four of the
CBCL scales their scores were statistically significantly worse:
Anxious/Depressed, Attention Problems, Rule-Breaking Behavior, and
Aggressive Behavior.
Tables 1.1 and 1.2 summarize the results of the two empirical studies
cited above.
Dyadic Developmental Psychotherapy is an affect-focused family
therapy based on Attachment Theory (Bowlby 1980, 1988; Holmes, 1993)
and draws on the best of several previously established, evidence-based
approaches, methods, and techniques that have a strong evidence base.
Dyadic Developmental Psychotherapy uses a variety of interventions and
methods with a well-established foundation. For example, Dyadic
Developmental Psychotherapy is consistent with the basic principles of
effective treatment for complex trauma (Cook et al., 2003, 2005). Cook et
al. identify six core components of complex trauma interventions: “safety,
self-regulation, self reflective information processing, traumatic experience
integration, relational engagement, and positive affect enhancements”
(Cook et al, 2005 p. 395). Dyadic Developmental Psychotherapy
emphasizes each of these six core components. Specific components,
methods, and principles of Dyadic Developmental Psychotherapy that have
good empirical support and are shared with other treatment approaches
(Orlinsky, Grawe, & Parks, 1994) include the following:

1. Affect arousal, a focus on problems of living and on core personal

relationships have been shown to be important for positive outcomes for
treatment.
2. Articulating how the past may continue to effect present behavior,
emotions, and interpretation has been found to be an effective mode of
intervention.
3. Forming and maintaining a therapeutic bond. This is a core component of
Dyadic Developmental Psychotherapy. The therapeutic attitude of PACE
(Playful, Accepting of the emotions and experience of the other, Curious
about how the person experiences the world and the meaning the person
ascribes to events, Empathy for the person) is designed specifically to
help facilitate the therapeutic relationship. There is a significant positive
association between outcome and the therapeutic bond (66 percent of the
studies with an effect size of at least .25 in one quarter of the studies, p.
308 of Orlinsky et al., 1994). In looking at the therapist’s contribution to
the therapeutic bond, a significant positive association with outcome was
found: “The therapist’s contribution was positively associated with
outcome 67% of the time and never negatively implicated” (p. 321). “The
strongest evidence linking process to outcome concerns the therapeutic
bond or alliance” (p. 360).
4. Acceptance. This is a significant dimension of the practice of Dyadic
Developmental Psychotherapy. Therapist affirmation (acceptance, non-
possessive warmth, or positive regard) was found to be a significant
factor in positive therapeutic outcome.
Overall such factors as empathy, the capacity for reflection, intersubjective
sharing of affect, the therapeutic alliance, furthering reflection, deepening
emotional processing, enhancing adaptive skills, developing and
maintaining the therapeutic bond, therapist affirmation, communication
attunement, and the bond of relatedness between therapist and patient are
all important factors in psychotherapy outcome and are all important
elements of Dyadic Developmental Psychotherapy.
The first section of this book describes places to begin, such as the
importance of getting a thorough assessment and what is an attachment
perspective and how this can explain behavior that otherwise may seem
incomprehensible. While getting a thorough assessment is neither unique
nor intrinsic to Dyadic Developmental Psychotherapy, I do consider it good
practice and so include it in this book.
The second section of this book describes fourteen major components of
Dyadic Developmental Psychotherapy. These components include:

Therapist use of self

Process focused: It’s about connections not compliance
PLACE & PACE (Playful, Loving, Accepting, Curious, Empathic &
Play-ful,
Accepting, Curious, Empathic)
Intersubjectivity
Reflective Capacity
Affective/Reflective dialogue
Commitment
Insightfulness
Coherent Narrative
Co-regulation of emotions
Co-creation of meaning
Follow-lead-follow
Interactive repair
Nonverbal-verbal dialogue

I then describe my thinking on phases of treatment as applied to the practice

of Dyadic Developmental Psychotherapy. This provides a framework for
understanding which elements of Dyadic Developmental Psychotherapy
may be more salient at that point in treatment. This chapter describes each
phase of treatment in detail and the mix of Dyadic Developmental
Psychotherapy components that may have more salience at that phase when
using Dyadic Developmental Psychotherapy. Clinical examples are used to
illustrate various points. The concept of phases is used as a teaching tool
and as an application of attachment theory to thinking about Dyadic
Developmental Psychotherapy, which is grounded in attachment theory. As
used in this book, the phases should not be construed as a rigid set of steps
that occur in a linear or prescribed manner. The reader can think of phases
in the same way that phases of the moon are viewed. The whole remains
present, but in different phases, different sections of that whole are
highlighted and appear more prominent. The use of phases to think about
practice can be experienced as one aspect of the reflective part of the
therapist’s own internal affective/ reflective dialogue. The therapist must
experience the clients in the moment (the affective dimension) while being
able to reflect on this experience and make sense of it (the reflective
dimension). The concept of phases can aid in this reflection. Feedback from
teaching workshops, seminars, and classes suggests that the concept of
phases can be useful when learning about Dyadic Developmental
Psychotherapy. These phases are: building the alliance (secure base),
maintaining the alliance, exploration, integration, and healing. The phases
occur in a cyclic sequential fashion and have substantial overlap. A
beginning alliance and exploration, integration, and healing can begin with
the first meeting, or may be spread out over an extended period of time.
Exploration, integration, and healing occur in a cyclical manner, deepening
as treatment proceeds.
 Chapter 2

First Things First

Before beginning treatment a thorough and comprehensive assessment of

the family, parents, and child should occur. While this is not an essential or
unique element of Dyadic Developmental Psychotherapy, it is generally
good practice and so is presented in this chapter as an “adjunct” to the
practice of Dyadic Developmental Psychotherapy. The material in this
chapter is largely a reflection of my own professional experience and
thinking about what constitutes a thorough assessment and evaluation. What
I present in this chapter are my views on assessment and my application of
various principles of Dyadic Developmental Psychotherapy to the
assessment process. As you will see, the focus is on what is causing
behavior, what is the intention, what is driving action; our primary concern
is the meaning of the behavior—Causes not Symptoms are the focus.
Children who have experienced chronic early maltreatment within a
caregiving relationship, Complex Trauma (Cook, Blaustein, Spinazolla, &
van der Kolk, 2003; Cook, Spinazzola, Ford, Lanktree, Blaustein, Cloitre, et
al., 2005), can have impairment in a variety of domains with symptoms
that, while looking quite similar, have quite distinct causes and, therefore,
require different treatments. Since we treat causes, it is vital to have a
thorough assessment. Complex Trauma can cause pervasive difficulties
across multiple domains. Effective treatment interventions require that we
understand the underlying nature and drivers of the problems we observe.
A comprehensive assessment should consider the family, parents, and
child. It should address the various domains that can be affected by
Complex Trauma (attachment, behavioral regulation, emotional regulation,