The following is a description of the Outpatient and brief Intensive Outpatient Dyadic Developmental Psychotherapy, an attachment-based therapy as practiced at The Center for Family Development. The therapy is designed to work with children who have a diagnosis of Reactive Attachment Disorder (RAD). Many of the children we see have been given a diagnosis of Oppositional Defiant Disorder, Post Traumatic Stress Disorder, Conduct Disorder, Attention Deficit/Hyperactivity Disorder, and/or Mood Disorder. All suffer from a prolonged or delayed grief reaction in response to one or more significant losses early in childhood. All have histories of early significant deprivation, neglect, and/or abuse.
Our therapists are involved in Dyadic Developmental Psychotherapy, an attachment-based therapy at our center. Each therapist is unique and has evolved a way of working that has been successful with difficult children and adolescents. Each client is also unique. The therapists, although they may use different approaches or techniques, all use attachment theory as the organizing construct that underlies their work. Therapy techniques vary to take advantage of the strengths of the therapist and to meet the specific needs of the client.
Most children we treat are severe in their pathology. Many have lived in one or more foster homes and have suffered neglect and physical and/ or sexual abuse. A high percentage of children treated here are adopted, many from overseas orphanages. Some experienced medical/pain trauma as infants or prolonged or frequent separations from primary attachment figures during the first two years of life. Almost all have had several years of therapy with one or more therapists. Some have been hospitalized one or more times. Whatever the help, there is little evidence of positive change as measured by improvement in the child's behavior and in his or her ability to trust. The following elements describe the attachment work done at The Center for Family Development.
Therapy for children with Reactive Attachment Disorder has three components. The first is designed to help parents understand children with attachment disorder: how they feel, how they think, and their internal psychological dynamics. The teaching of attuned and responsive parenting skills comprises the second part. These skills are designed to help the parents engage the child emotionally in a growth enhancing relationship. We use the model of creating a healing PLACE. PLACE stands for being playful, loving, accepting, curious, and empathic. The third component involves intensive emotional work with the child. This part constitutes a significant portion of the treatment.
The basic purpose of treatment is to help the child resolve a dysfunctional attachment and develop a healthy attachment. The goal is to help the child bond to the parents and to come to grips with the disappointment, sadness, fear, and anger at the first attachment figure(s) and their failure to parent. Said another way, the goal is to resolve the fear of loving and being loved. The parent’s own family of origin issues are also a focus of treatment as these may create difficulties in the current relationship with their child.
Structure and Duration
In the regular outpatient program, families are usually seen initially for a two-hour session weekly. Two therapists maybe involved, when indicated. Most of the children we treat are seen weekly.
When families reside far away from the Center, they may decide to engage in a Two-Week Intensive. In some instances, a child does not respond to weekly Dyadic Developmental Psychotherapy, an attachment-based therapy and requires more intensity, in which case a Two-Week Intensive may be indicated. In the Intensive Program, we work for ten consecutive days (two weeks), three hours per day. This is an outpatient facility. Families stay at local hotel or with friends or family nearby. Two therapists are used. If indicated, the child may stay in a therapeutic foster family for all or part of the two weeks. The time in therapy is divided between working with the parents, with the child/adolescent, and sometimes with other members of the family. Referring therapists are encouraged to come with the family and be a part of the therapeutic team, if they are available to follow-up with the family after the two-week intensive. The treatment team includes the therapists, parents, family, specialist, and others.
Treatment always involves the child and the parents. Sometimes we involve siblings as the child has often abused them and corrective work is needed for these relationships. The parents are involved in all treatment. They are either in the therapy room directly or are watching therapists work with the child from an observation room.
Many of the parents are feeling "burned out" by their child's pathology. They have often been emotionally abused, particularly the mother. Since one of the goals of therapy is to help the parents get "in charge" in a good way, the parenting coalition must be solid. To that end, sometimes the therapy process will focus on the parents' release of old anger, on relationship issues, and sometimes on un-addressed emotional issues of one or both parents, which inhibit the formation of strong attachment bonds.
Dyadic Developmental Psychotherapy, an attachment-based therapy.
As mentioned above, therapy has three components. The first is educational, designed to help parents understand children with attachment disorder: how they feel, how they think, and their internal psychological dynamics. The teaching of consequential parenting skills comprises the second part. These skills are designed to help the parents protect themselves from the child's pathology and to provide necessary corrective parenting experiences for the child. Consequential parenting also serves to heighten the child's motivation for treatment by allowing them to experience the pain of their condition rather than displacing it on the parents. The third component involves intensive emotional work with the child. This part constitutes a significant portion of the treatment.
The basic purpose of treatment is to help the child resolve a dysfunctional attachment and develop a healthy attachment. The goal is to help the child bond to the parents and to come to grips with the disappointment and anger at his/her first attachment figure(s) and their failure to parent (well). Said another way, the goal is to resolve the fear of loving and being loved. All of the children who come for treatment have authority or control issues. Control, trust, and intimacy issues are prominent features of their pathology and the resolution of these issues is a major treatment objective.
In addition to using standard verbal psychotherapy techniques, we use techniques designed to engage the child in corrective emotional experiences. Our child clients made decisions about trust early in their lives. These survival decisions were made as infants or very young children, made before they had language to encode the meaning of what was happening, even to themselves. Their trauma is locked into the experience of having felt pain at a time when they were powerless to get the help they needed. A variety of therapeutic techniques (psychodrama, imagery, social skill-building) are used to elicit and correct the child's pathology.
A major dynamic in treatment is to help the child address the trauma 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.
The therapy has a major emotional or affective emphasis. We operate with the philosophy that emotions have a major causative effect on behavior. We believe that when the emotions that cause the behavior change, the behaviors will change, often with little or no discussion. In our experience, the trauma the children have experienced, which often includes the loss of their birth mothers, neglect, and abuse, produces three major emotions: fear, sadness, and anger. These emotions provide the causal energy for most of the child's pathological behavior. These emotions underlie their avoidance of attachment. Consequently, the regressive work that helps them access their fear, sadness, and anger is a process that helps them heal from their emotional trauma(s).
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. In our experience, 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" does not mean hostile or punishing. It means dealing directly with the heart of the child's experience. A contract made with the child includes an agreement that the therapists direct the therapy. 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. Consequently, therapy is quite confrontive and the child, as part of the contract, must agree to acknowledge the problems that brought the family to treatment and ask us for help. In our experience, when addressed in a forthright, open, and realistic manner, children almost always respond in the affirmative.
In essence, all therapy conducted at The Center for Family Development is done under three clear contracts. The most essential is the one between the parent and the child. The parent must be able to get the child to acknowledge and accept the reality of the problems and get the child to know that, while not responsible for the cause, he/she must accept responsible participation in its cure. The other two contracts are between the parents and the therapists and between the therapists and the child.
The course of therapy takes into account the unique needs of each family and child. Perhaps the most critical factor in positive treatment outcomes are parents who are strong, committed, compassionate, and open to their own emotional growth and to learning and applying parenting skills specific to their child's needs. The skill of the clinicians in selecting and implementing treatment strategies most appropriate to each child and family is also a considerable factor in outcomes of this therapy.
Dyadic Developmental Psychotherapy, an attachment-based therapy at The Center for Family Development is often the treatment of choice in cases where able parents have a child who had a traumatic first two years of life and defends against accepting parental control and good judgment.
Children do heal, there is hope.