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.
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.
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
ATTACHMENT-FOCUSED CARE WITH TRAUMATIZED, DISORGANIZED CHILDREN
1.Accepting 2. Curious 3. Empathic
4. Loving 5. Playful (PLACE)
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 firstname.lastname@example.org
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”.
Dan Hughes email@example.com
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.- - - - - _____ _____
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?
Dan Hughes firstname.lastname@example.org
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.
Shame and Guilt
Decrease the One, While Increasing the Other
DIFFERENCES SHAME GUILT
Focus of evaluation Global Self Specific Behavior
Degree of distress More Painful Less Painful
Phenomenological exp Feel small, worthless Tension, remorse
Powerless, shrinking Regret
Operation of “self” Split: observing/observed Unified self intact
Impact on “self” Impair: Global Devaluation Minimal
Primary Concern Other’s evaluation of self Effects of behavior on other
Counterfactual processes Mentally undoing part of self Mentally undoing behavior
Motivational feature Want to hide; strike back Want to confess; repair
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 email@example.com
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
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.
Expression of experience of B/E
Coherent, comprehensive, succinct
Blend of specific/general
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
Affect: Interests & Joy toward objects/others/self
Fear, sadness, anger
Shame & Guilt
Response to PACE
Sense of autobiographical narrative
Sense of efficacy
Dan Hughes firstname.lastname@example.org
AFFECTIVE/REFLECTIVE (A/R) DIALOGUE
Child: “You don’t really care!!”
Clarify, Elaborate, Explore His Subjective Experience:
Empathy: If you think that I don’t care, that must be hard for you!
EMPATHY: I feel sad that you experience me as not caring.
Associated feelings: How does it feel to be with someone you don’t think cares?
Associated thoughts: If I don’t care for you, why do you think I don’t?
Implications: What does it mean if I don’t care?
Coping strategies: How do you handle it, talking with someone you don’t think cares?
General coping: What do you do when you think someone doesn’t care for you?
Patterns: Do you have that experience with someone in your family/friend?
Self-worth: If you think I don’t care, does it effect what you think about yourself?
Ass. Experiences: Are there other times when you have the same thoughts about yourself
Here & Now: How does it feel now talking with me when you think I don’t care.
I-Messages: 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!
Archer, C. (1999). First steps in parenting the child who hurts. London: Jessica Kingsley.
Archer, C. (1999). Next steps in parenting the child who hurts. London: Jessica Kingsley.
Archer, C. & Gordon, C. (2006). New families, old scripts. London: Jessica Kingsley.
Becker-Weidman, A. & Shell, D. (Eds.) (2005). Creating capacity for attachment.
Oklahoma: Wood N’ Barnes.
Becker-Weidman, A. & Shell, D. (Eds.) (2010). Attachment parenting: developing connections and healing children. Lanham, MD: Jason Aronson.
Bloom, S. (1997). Sanctuary. New York: Routledge.
Bomber, L. (2007). Inside I’m Hurting. London: Worth Publishing.
Bowlby, J. (1969). Attachment and loss: Vol.1. Attachment. New York: Basic Books.
Cassidy, J. & Shaver, P.R.(Eds.) (2008) Handbook of attachment, 2nd Ed. New York:
Cicchetti, D., Toth, S., & Lynch, M. (1995). Bowlby’s dream comes full circle: The application of attachment theory to risk and psychopathology. Advances in Clinical Child Psychology, 17, 1-75.
Cozolino, L. (2002). The neuroscience of psychotherapy. New York: W.W.Norton.
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,
Field, T. (2002). Touch. Cambridge, MA: MIT Press.
Fonagy, P., Gergely, G., Jurist, E., Target, M. (2002). Affect regulation, mentalization,
and the development of the self. New York: Other Press.
Fosha, D. (2000). The transforming power of affect. New York: Basic Books.
Fosha, D., Siegel, D. & Solomon, M. (Eds.) (2009). The healing power of emotion.
New York: WWNorton.
Fosha, D. (2003). Dyadic regulation and experiential work with emotion and
relatedness in trauma and disorganized attachment. In M.F.Solomon & D.J.
Siegel, (Eds.) Healing trauma: attachment, mind, body, and brain. New York:
Gold, S. (2000) Not trauma alone. Philadelphia: Brunner/Routledge.
Golding, K. (2008). Nurturing attachments: supporting children who are fostered or
adopted. London: Jessica Kingsley.
Gray, D. (2002). Attaching in adoption. Indianapolis, IN: Perspectives Press.
Gray, D. (2007). Nurturing Adoptions. Indianapolis: Perspectives Press.
Hesse, E. (2008). The adult attachment interview: protocol, method of analysis, and
empirical studies. In Cassidy, J. & Shaver, P.(Eds) Handbook of Attachment, 2nd.Ed. New York: Guilford.
Hobson, P. (2002). The cradle of thought. London: Macmillan.
Hughes, D. (2006). Building the bonds of attachment 2nd Ed. Northvale, NJ: Jason
Hughes, D. (2007) Attachment-focused family therapy. New York: W.W.Norton.
Hughes, D. (2009). Attachment-focused parenting. New York: W.W.Norton.
Hughes, D. (projected 2011). Attachment-focused family therapy workbook.
New York: W.W.Norton.
Hughes, D. (2004). An attachment-based treatment of maltreated children and young
people. Attachment & Human Development, 6, 263-278.
Hughes, D. (2009). Principles of attachment and intersubjectivity: still relevant in relating with adolescents. In Teenagers and attachment: helping adolescents engage with life and learning. A. Perry, (Ed.) London: Worth Publishing. 123- 140.
Hughes, D. (2009). Attachment-Focused Treatment for Children. In Clinical pearls of wisdom. Kerman, M. (Ed.). New York: Norton. 169-181.
Hughes, D. (2009). The Communication of Emotions and the Growth of Autonomy
and Intimacy within Family Therapy. In The healing power of emotion: affective neuroscience, development, and clinical practice. New York: Norton. Pp.280- 303.
Jernberg, A.M. & Booth, P.B. (1999). Theraplay. (2nd Ed.) San Francisco: Jossey-Bass.
Johnson, S.M.(2004) The practice of emotionally focused couple therapy: Creating
Connections 2nd Ed. New York: Brunner-Routledge.
Johnson, S.M. (2002). Emotionally focused couple therapy with trauma survivors:
strengthening attachment bonds. New York: Guilford.
Karen, R. (1994). Becoming attached. New York: Warner Books.
Kaufman, G. (1996). The psychology of shame. New York: Springer.
Klaus, M. & Klaus, P. (1998). Your amazing newborn. Reading, MA: Perseus Books.
Kohn, A. (1993). Punished by rewards. New York: Houghton Mifflin.
Kohn, A. (2005). Unconditional Parenting. New York: Atria Books.
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.
Morin, V. K. (1999). Fun to grow on. Chicago: Magnolia Street Publishers.
O’Connor, T.G., & Zeanah, C.H. (2003). Current perspectives on attachment disorders:
Rejoinder and synthesis. Attachment and Human Development, 5, 321-326.
Panksepp, J. (2001). The long-term psychobiological consequences of infant emotions:
prescriptions for the twenty-first century. In Infant mental health journal, 22,
Perry, A. (ed.) (2009). Teenagers and attachment. London: Worth Publishing.
Perry, B. & Szalavitz (2006). The boy who was raised as a dog. New York: Basis Books.
Putnam, F.W. (1997) Dissociation in children and adolescents. New York: Guilford.
Schore, A.N. (2001) Effects of a secure attachment on right brain development, affect
regulation, and infant mental health. Infant mental health journal, 22,7-67.
Schore, A.N. (2003a). Affect disregulation and disorders of the self. New York:
Schore, A.N. (2003b). Affect regulation and the repair of the self. New York:
Siegel, D.J. (1999). The developing mind. New York: Guilford.
Siegel, D.J. (2001) Toward an interpersonal neurobiology of the developing mind:
attachment relationships, “mindsight”, and neural integration. Infant mental health journal, 22, 67-94.
Siegel, D.J. & Hartzell, M. (2003). Parenting from the inside out. New York:
Jeremy P. Tarcher/Putnam.
Siegel, D.J. (2007). The mindful brain. New York: W.W.Norton.
Siegel, D.J. (2010). Mindsight: the new science of personal transformation. NY: Bantam.
Siegel, D.J. (2010) The Mindful Therapist. New York: Norton.
Steele, M., Hodge, J., Kaniuk, J., Hillman, S. & Henderson, K. (2003). Attachment
representations and adoption: associations between maternal states of mind and
emotion narratives in previously maltreated children. Journal of Child Psychotherapy, 29, 187-205.
Solomon, M.F. & Siegel, D.(2003) Healing Trauma. NY: W.W.Norton.
Sroufe, L.A., Egeland, B., Carlson, E. & Collins, W.A. (2005). The development of the
person. New York: Guilford.
Stern, D. (1985). The interpersonal world of the infant. New York: Basic Books.
Stern, D. (2004). The present moment in psychotherapy and everyday life. New York:
Sunderland, M. (2006) The science of parenting. New York: DK Publishing
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.
Tangney, J. & Dearing, R. (2002). Shame and guilt. NY: Guilford Press.
Tronick, E. (2007). The neurobehavioral and social-emotional development of infants
and children. NY: W.W.Norton.
Trout, M. & Thomas, L. (2005). The Jonathon Letters. Champaign, Il: The Infant-
Parent Institute, Inc.
Weininger, O. (2002). Time-in Parenting. Toronto, Ontario: Rinascente Books
British Psychological Society-Division of Clinical Psychology
Faculty for Children and Young People
Service & Practice Update, 4, 4, 26-28. December 2005
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 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 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.
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.