Dyadic Developmental Psychotherapy (DDP)

Dyadic developmental psychotherapy (DDP) is an attachment-focused therapy developed by Drs. Daniel Hughes and Arthur Becker-Weidman. It is an evidence-based treatment for complex trauma, reactive attachment issues (RAD), and other issues with attachment. It is often used to treat children in foster care and adoptive families, especially those who have experienced trauma, abuse, or neglect. DDP is a family-focused approach to therapy that incorporates well-researched principles such as a focus on relationships, attunement, intersubjectivity, and sensitive responsiveness.

• What is Dyadic Developmental Psychotherapy?
• Key Principles of DDP
• Contributing Theories of DDP
• Application and Efficacy of DDP
• How Does DDP Work?
• History of DDP
• Criticisms and Limitations of DDP

What Is Dyadic Developmental Psychotherapy?

According to Dr. Becker-Weidman, one of the primary developers, this form of psychotherapy was originally developed as an intervention for children who have experienced emotional trauma as a result of chronic early maltreatment within the caregiving relationship. The primary goal of DDP is to support these children in developing the ability to maintain attachment-based relationships with parents and caregivers. The approach is grounded in various theories, including the attachment theory and the work of John Bowlby and Daniel Stern.

Key Principles of DDP

Listed below are a few of the key principles and concepts of dyadic developmental psychotherapy:

• Attachment: Attachment is a blanket term that describes a type of emotional relationship that develops between child and caregiver, in which the child seeks psychological and physical safety. Successful attachment provides the child with comfort, security, and an environment in which to thrive. Secure attachment positively affects the child's cognitive, emotional, and physical development.
• Developmental Trauma: This term refers to early childhood trauma that directly impacts a child's development. This often involves traumatic events, abuse, or neglect that took place as a result of the parent's inability to fulfill the role of protector. Developmental trauma can cause problems for a child later in life, including impaired development, relational problems, and behavioral issues.
• Intersubjectivity: This term refers to a dynamic that plays out between two people who share a mutual experience. In other words, intersubjectivity occurs within a reciprocal relationship in which each person influences the experience of the other.   
• Relationship-Focused: The treatment is primarily a family therapy and relationship-focused treatment.

Contributing Theories of DDP

DDP is rooted in several theoretical frameworks including attachment theory, interpersonal neurobiology, development, and intersubjectivity. Overall, the theoretical basis for DDP postulates that when children are exposed to trauma at a young age, it interferes with the brain's emotional and physical development. Children struggle to develop secure attachments with their caretakers because they are the source of both fear and of safety. This confusing relationship development often impacts how they make sense of their world and their sense of self, resulting in an incoherent, jumbled narrative about who they are and how they should navigate their world.

When children are then placed in homes later in life with loving and devoted caregivers, they are sometimes unsure about what to make of this kind of nurturing. Conflict and maladaptive patterns of behavior tend to play out and prevent healing from taking place in their new environments. DDP therapists work to rebuild and repair the relationship by teaching the parents a form of parenting that responds to the unique circumstances of their children. Children are also taught emotion regulation, how to trust their parents, and new ways of understanding of their life experiences.

Application and Efficacy of DDP

In dyadic developmental psychotherapy, the therapist's role is to help improve the parent-child relationship. The therapist focuses on helping the caregivers provide responsive, sensitive care for their child. This is done by establishing an environment of safety in which the child in therapy can explore memories, emotions, and current experiences that may be frightening, stressful, avoided, or altogether denied.

According to Dr. Becker-Weidman, “Safety in DDP is established by ensuring that memories, experiences, and emotions are explored with nonverbal attunement, reflective and non-judgmental dialogue, empathy, and reassurance. As a result, the child in therapy is able to create an autobiographical narrative crucial for healthy attachment security. This process can also help a child form strong protective defenses for future mental health issues.”

The DDP Network and relevant literature claim many children and families experience the following benefits from dyadic developmental psychotherapy:

• Reduction in controlling behaviors
• Improved quality of relationship and bond
• Improved ability to cope with stress and improved emotion regulation
• Increased insight into emotional experiences
• Improved interpersonal relationship skills
• Increased sense of safety and security with caretakers

In addition to these reported benefits, available research suggests that attuned, nurturing, and responsive parenting fosters healthy brain development and solid emotional relationships between parents and children. The Dyadic Developmental Psychotherapy Institute (DDPI) is devoted to expanding DDP's research base to include randomized controlled trials to further promote its efficacy.

How Does DDP Work?

DDP therapists begin treatment by teaching parents PACE parenting. PACE stands for playful, accepting, curiosity, and empathy. Parents are taught to interact with their child and work to understand their child's behavior, all while remaining calm (emotionally regulated), even in tough situations.

In general, DDP treatment adheres to the following structure:

1. The therapist starts by getting to know the parents, assessing their parenting styles, and then teaching them the PACE method.
2. The therapist then helps parents practice and prepare for their role in the therapeutic process of engaging their child in session. Part of this preparation includes the exploration of the parents' own attachment histories and how they may be triggered by their child's behavior.
3. When the therapist believes the parents are ready, the child is invited into therapy.
4. The therapist will spend time modeling how to talk with the child, ascertaining the child's own understanding of his or her history, and teaching the child emotion regulation.
5. The therapist will then ask the child to talk with his or her parents and a theme will be identified. For example, the theme of abandonment may come up. The therapist will assist parents and their child in their interaction, helping them explore the chosen theme safely. The therapist will coach the parents to help the child make new meaning out of the abandonment that was experienced.
6. The therapist will conduct several sessions in this manner and will occasionally have parent sessions in order to check in and recalibrate as needed.
7. Treatment will be terminated when the therapist assesses that the child is securely attached and the intersubjective connection occurs without the aid of the therapist.

History of DDP

While working with children and their foster and adoptive families in the 1980s, clinical psychologists Dan Hughes and Arthur Becker-Weidman were challenged to find a method of treatment that brought about lasting results. They became frustrated by the fact that no matter what parenting techniques they would offer, the children who had experienced early trauma, abuse, or neglect would still struggle in their relationships with their foster or adoptive parents.

The psychologists reacquainted themselves with attachment theory and soon realized that unlike securely attached children, the children they were working with did not look to their parents for comfort during times of stress. Intrigued by this difference, Hughes and Becker-Weidman developed a specialized form of parenting that met the unique needs of the children who had suffered at the hands of their early attachment figures. Becker-Weidman began integrating the work of John Bowlby and others and adapted a parenting style along with treatment techniques that specifically targeted the effects of developmental trauma. In the late 80s, the initial model of dyadic developmental psychotherapy was in development.

Since then, DDP has expanded throughout the U.S. and internationally to include Singapore, Australia, UK, Canada, Finland, Slovakia, and the Czech Republic. In 2009, the Attachment-Focused Treatment Institute was founded to oversee the training, certification, accreditation, research, and expansion of DDP.

Criticisms and Limitations of DDP

One limitation of DDP is that it is primarily geared toward foster and adoptive families. There are many children who have experienced early childhood trauma that remain in the care of their abusive or neglectful parents. Some of these parents have been able to find a therapist to help address the root of their abusive behavior, but they may be ill equipped to repair the damage done. To help address the needs of families experiencing these circumstances, DDP has been adapted by Becker-Weidman.

One common criticism of DDP is the lack of randomized clinical trials to support the efficacy of DDP. However, dyadic developmental psychotherapy adheres to established research practices that value the therapeutic relationship as a strong predictor of outcomes. Additionally, the Dyadic Developmental Psychotherapy Institute is actively engaged in data collection efforts. It should also be noted that this model of therapy has been found to be an evidence-based treatment by the California Evidence-Based Clearinghouse for in Child Welfare and in several peer-reviewed professional publications.

References:

1. Attachment-Focused Treatment Institute. (n.d.). Certification in dyadic development psychotherapy. Retrieved from http://www.attachment-focusedtreatmentinstitute.com/
2. Becker-Weidman, A., & Shell, D., (Eds.) (2010). Attachment Parenting: Developing Connections and Healing Children, Lanham, MD: Jason Aronson.
3. Becker-Weidman, A., (2012) Dyadic developmental psychotherapy: effective treatment for complex trauma and disorders of attachment. Illinois Child Welfare Journal, 6(1), pp 1-11.
4. Becker-Weidman, A., (2012) The Dyadic Developmental Psychotherapy Primer, Williamsville, NY: Century.
5. Becker-Weidman, A., (2008) "Treatment for children with reactive attachment disorder: dyadic developmental psychotherapy" Child and Adolescent Mental Health, Volume 13 (1), 2008, pp. 52-60.
6. The California Evidence-Based Clearinghouse for Child Welfare Information and Resources for Child Welfare Professionals. (n.d.). Dyadic developmental psychotherapy. Retrieved from http://www.cebc4cw.org/program/dyadic-developmental-psychotherapy/detailed
7. Dyadic Developmental Psychotherapy (n.d.). In DDP Network. Retrieved from http://ddpnetwork.org/about-ddp/dyadic-developmental-psychotherapy/
8. Examining Dyadic Developmental Psychotherapy as a treatment for adopted and foster children: a review of research and theory’. (2014, October 28). In DDP Network. Retrieved from http://ddpnetwork.org/backend/wp-content/uploads/2014/10/DDPI-Board-statement-re-Dr-Jean-Mercer-Research-on-Social-Work-Practice-2014.pdf
9. Hughes, D. (2014). Dyadic Developmental Psychotherapy Goals and Objectives. In DDP Network. Retrieved from http://ddpnetwork.org/backend/wp-content/uploads/2014/03/DDP-Goals-and-Objectives-290314.pdf
10. Hughes, D. (2014, February). How I founded DDP: A personal perspective from Dan Hughes. In DDP Network. Retrieved from http://ddpnetwork.org/backend/wp-content/uploads/2014/03/How-I-founded-DDP-Dan-Hughes-05.02.14.pdf
11. Phillips, S. (2013, October 13). Why DDP? An interpersonal neurobiology perspective. In DDP Network. Retrieved June 25, 2015, from http://ddpnetwork.org/backend/wp-content/uploads/2014/02/Why-DDP.pdf
12. Research, Evidence Base, and Outcomes. (n.d.). In DDP Network. Retrieved http://ddpnetwork.org/about-ddp/research-evidence-base-outcomes/