Dyadic Developmental Psychotherapy: an Evidence-based Treatment for Disorders of Attachment; the Empirical Support

Ã‚				relationships.
Dyadic Developmental Psychotherapy (DDP) is an				6. Caregivers use attachment-facilitating
evidence-based and effective form of treatment				interventions.
for children with trauma and disorders of				7. Use of a variety of interventions, including
attachment[1]. It is an evidence-based treatment,				cognitive-behavioral strategies.
meaning that there has been empirical research				Dyadic Developmental Psychotherapy
published in peer-reviewed journals. Craven & Lee				interventions flow from several theoretical and
(2006) determined that DDP is a supported and				empirical lines. Attachment theory (Bowlby, 1980,
acceptable treatment (category 3 in a six level				Bowlby, 1988) provides the theoretical foundation
system). However, their review only included				for Dyadic Developmental Psychotherapy. Early
results from a partial preliminary presentation of				trauma disrupts the normally developing
an ongoing follow-up study, which was				attachment system by creating distorted internal
subsequently completed and published in 2006.				working models of self, others, and caregivers.
This initial study compared the results of Dyadic				This is one rationale for treatment in addition to
Developmental Psychotherapy with other forms				the necessity for sensitive care-giving. As
of treatment, 'usual care', 1 year after treatment				O'Connor & Zeanah (2003, p. 235) have stated,
ended. It is important to note that over 80% of				"A more puzzling case is that of an adoptive
the children in the study had had over three prior				foster caregiver who is 'adequately' sensitive but
episodes of treatment, but without any				the child exhibits attachment disorder behavior; it
improvement in their symptoms and behavior.				would seem unlikely that improving parental
Episodes of treatment mean a course of therapy				sensitive responsiveness (in already sensitive
with other mental health providers at other clinics,				parent) would yield positive changes in the
consisting of at least five sessions. A second				parent-child relationship." Treatment is necessary
study extended these results out to 4 years				to directly address the rigid and dysfunctional
after treatment ended. Based on the Craven &				internalized working models that traumatized
Lee classifications (Saunders et al. 2004), inclusion				children with attachment disorders have
of those studies would have resulted in Dyadic				developed.
Developmental Psychotherapy being classified as				Current thinking and research on the neurobiology
an evidence-based category 2, 'Supported and				of interpersonal behavior (Siegel, 1999, Siegel,
probably efficacious'. There have been two related				2000, Siegel, 2002, Schore, 2001) is another part
empirical studies comparing treatment outcomes				of the foundation on which Dyadic Developmental
of Dyadic Developmental Psychotherapy with a				Psychotherapy rests.
control group. This is the basis for the rating of				The primary approach is to create a secure base
category two. The criteria are:				in treatment (using techniques that fit with
* 1. The treatment has a sound theoretical basis				maintaining a healing PACE (Playful, Accepting,
in generally accepted psychological principles.				Curious, and Empathic) and at home using
Dyadic Developmental Psychotherapy is based in				principals that provide safe structure and a healing
Attachment Theory (see texts cited below				PLACE (Playful, Loving, Acceptance, Curious, and
* 2. A substantial clinical, anecdotal literature exists				Empathic). Developing and sustaining an attuned
indicating the treatment's efficacy with at-risk				relationship within which contingent collaborative
children and foster children.				communication occurs helps the child heal.
See reference list.				Coercive interventions such as rib-stimulation,
* 3. The treatment is generally accepted in clinical				holding-restraining a child in anger or to provoke
practice for at risk children and foster children.				an emotional response, shaming a child, using fear
As demonstrated by the large number of				to elicit compliance, and interventions based on
practitioners of Dyadic Developmental				power/control and submission, etc., are never
Psychotherapy and it's presentation as numerous				used and are inconsistent with a treatment rooted
international and national conferences over the last				in attachment theory and current knowledge
ten or fifteen years.				about the neurobiology of interpersonal behavior.
* 4. There is no clinical or empirical evidence or				The usual structure of a session involves three
theoretical basis indicating - that the treatment				components. First, the therapist meets with the
constitutes a substantial risk of harm to those				caregivers in one office while the child is seated in
receiving it, compared to its likely benefits.				the treatment room. During this part of
* 5. The treatment has a manual that clearly				treatment, the caregiver is instructed in
specifies the components and administration				attachment parenting methods (Becker-Weidman
characteristics of the treatment that allows for				& Shell (2005) Hughes, 2006). The caregiver's
implementation.				own issues that may create difficulties with
Creating Capacity for Attachment, Building the				developing affective attunement with their child
Bonds of Attachment, and Attachment Focused				may also be explored and resolved. Effective
Family Therapy constitute such material.				parenting methods for children with
* 6. At least two studies utilizing some form of				trauma-attachment disorders require a high
control without randomization (e.g., wait list,				degree of structure and consistency, along with
untreated group, placebo group) have established				an affective milieu that demonstrates playfulness,
the treatment's efficacy over the passage of				love, acceptance, curiosity, and empathy (PLACE).
time, efficacy over placebo, or found it to be				During this part of the treatment, caregivers
comparable to or better than an already				receive support and are given the same level of
established treatment.				attuned responsiveness that we wish the child to
See ref. list				experience. Quite often caregivers feel blamed,
* 7. If multiple treatment outcome studies have				devalued, incompetent, depleted, and angry.
been conducted, the overall weight of evidence				Parent-support is an important dimension of
supported the efficacy of the treatment.				treatment to help caregivers be more able to
These studies support several of O'Connor &				maintain an attuned connecting relationship with
Zeanah's[2] conclusions and recommendations				their child. Second, the therapist with the
concerning treatment. They state (p. 241),				caregivers meets with the child in the treatment
"treatments for children with attachment				room. This generally takes one to one and a half
disorders should be promoted only when they are				hours. Third, the therapist meets with the
evidence-based."				caregivers without the child. Broadly speaking, the
Dyadic Developmental Psychotherapy, as with				treatment with the child uses three categories of
any specialized treatment, must be provided by a				interventions: affective attunement, cognitive
competent, well-trained, licensed professional.				restructuring, and psychodramatic reenactments.
Dyadic Developmental Psychotherapy is a				Treatment with the caregivers uses two
family-focused treatment[3].				categories of interventions: first, teaching
Dyadic Developmental Psychotherapy is the name				effective parenting methods and helping the
for an approach and a set of principals that have				caregivers avoid power struggles and, second,
proven to be effective in helping children with				maintaining the proper PLACE or attitude.
trauma and attachment disorders heal; that is,				Treatment of the child has a significant non-verbal
develop healthy, trusting, and secure relationships				dimension since much of the trauma took place at
with caregivers. Treatment is based on five				a pre-verbal stage and is often dissociated from
central principals.				explicit memory. As a result, childhood
At the core of Reactive Attachment Disorder is				maltreatment and resultant trauma create
trauma caused by significant and substantial				barriers to successful engagement and treatment
experiences of neglect, abuse, or prolonged and				of these children. Treatment interventions are
unresolved pain in the first few years of life.				designed to create experiences of safety and
These experiences disrupt the normal attachment				affective attunement so that the child is
process so that the child's capacity to form a				affectively engaged and can explore and resolve
healthy and secure attachment with a caregiver is				past trauma. This affective attunement is the
distorted or absent. The child lacks a sense trust,				same process used for non-verbal communication
safety, and security. The child develops a				between a caregiver and child during attachment
negative working model of the world in which:				facilitating interactions (Hughes, 2003, Siegel, 2001).
ÃƒÂ˜ Adults are experienced as				The therapist and caregivers' attunement results
inconsistent or hurtful.				in co-regulation of the child's affect so that is it
ÃƒÂ˜ The world is viewed as chaotic.				manageable. Cognitive restructuring interventions
ÃƒÂ˜ The child experiences no effective				are designed to help the child develop secondary
influence on the world.				mental representations of traumatic events, which
ÃƒÂ˜ The child attempts to rely only on				allow the child to integrate these events and
him/her self.				develop a coherent autobiographical narrative.
ÃƒÂ˜ The child feels an overwhelming				Treatment involves multiple repetitions of the
sense of shame, the child feels defective, bad,				fundamental caregiver-child attachment cycle. The
unlovable, and evil.				cycle begins with shared affective experiences, is
Reactive Attachment Disorder is a severe				followed by a breach in the relationship (a
developmental disorder caused by a chronic				separation or discontinuity), and ends with a
history of maltreatment during the first couple of				reattunement of affective states. Non-verbal
years of life. Reactive Attachment Disorder is				communication, involving eye contact, tone of
frequently misdiagnosed by mental health				voice, touch, and movement, are essential
professionals who do not have the appropriate				elements to creating affective attunement.
training and experience evaluating and treating				The treatment provided often adhered to a
such children and adults. Often, children in the child				structure with several dimensions. It is pictured in
welfare system have a variety of previous				Figure 1, below. First, behavior is identified and
diagnoses. The behaviors and symptoms that are				explored. The behavior may have occurred in the
the basis for these previous diagnoses are better				immediate interaction or have occurred at some
conceptualized as resulting from disordered				time in the past. Using curiosity and acceptance
attachment. Oppositional Defiant Disorder				the behavior is explored. Second, using curiosity
behaviors are subsumed under Reactive				and acceptance the behavior is explore and the
Attachment Disorder. Post Traumatic Stress				meaning to the child begins to emerge. Third,
Disorder symptoms are the result of a significant				empathy is used to reduce the child's sense of
history of abuse and neglect and are another				shame and increase the child's sense of being
dimension of attachment disorder. Attention				accepted and understood. Forth, the child's
problems and even Psychotic Disorder symptoms				behavior is then normalized. In other words, once
are often seen in children with disorganized				the meaning of the behavior and its basis in past
attachment[4].				trauma is identified, it becomes understandable
Approximately 2% of the population is adopted,				that the symptom is present. An example of
and between 50% and 80% of such children have				such an interaction is the following:
attachment disorder symptoms[5]. Many of these				Wow, I see how you got so angry when your
children are violent[6] and aggressive[7] and as				Mom asked you to pick up your toys. You
adults are at risk of developing a variety of				thought she was being mean and didn't want you
psychological problems[8] and personality				to have fun or love you. You thought she was
disorders, including antisocial personality disorder[9],				going to take everything away and leave you like
narcissistic personality disorder, borderline				your first Mom did, like when your first Mom took
personality disorder, and psychopathic personality				your toys and then left you alone in the
disorder[10]. Neglected children are at risk of social				apartment that time. Oh, I can really understand
withdrawal, social rejection, and pervasive feelings				now how hard that must be for you when Mom
of incompetence[11]. Children who have histories				said to clean up. You really felt mad and scared.
of abuse and neglect are at significant risk of				That must be so hard for you.
developing Post Traumatic Stress Disorder as				Ã‚
adults[12]. Children who have been sexually abused				Fifth, the child communicates this understanding to
are at significant risk of developing anxiety				the caregiver.
disorders (2.0 times the average), major				Sixth, finally, a new meaning for the behavior is
depressive disorders (3.4 times average), alcohol				found and the child's actions are integrated into a
abuse (2.5 times average), drug abuse (3.8 times				coherent autobiographical narrative by
average), and antisocial behavior (4.3 times				communicating the new experience and meaning
average)[13] (MacMillian, 2001). The effective				to the caregiver.
treatment of such children is a public health				Past traumas are revisited by reading documents
concern (Walker, Goodwin, & Warren, 1992).				and through psychodramatic reenactments. These
Left untreated, children who have been abused				interventions, which occur within a safe attuned
and neglected and who have an attachment				relationship, allow the child to integrate the past
disorder become adults whose ability to develop				traumas and to understand the past and present
and maintain healthy relationships is deeply				experiences that create the feelings and thoughts
damaged. Without placement in an appropriate				associated with the child's behavioral disturbances.
permanent home and effective treatment, the				The child develops secondary representations of
condition will worsen. Many children with				these events, feelings and thoughts that result in
attachment disorders develop borderline				greater affect regulation and a more integrated
personality disorder or anti-social personality				autobiographical narrative.
disorder as adults[14].				As described by Hughes (2006, 2003), the
FIRST PRINCIPAL. Therapy must be experiential.				therapy is an active, affect modulated experience
Since the roots of disorders of attachment occur				that involves acceptance, curiosity, empathy, and
pre-verbally, therapy must create experiences				playfulness. By co-regulating the child's emerging
that are healing. Experiences, not words, are one				affective states and developing secondary
"active ingredient" in the healing process.				representations of thoughts and feelings, the
For example, one eight year old boy who had				child's capacity to affectively engage in a trusting
Reactive Attachment Disorder, Bipolar Disorder,				relationship is enhanced. The caregivers enact
and a variety of sensory-integration disorders				these same principals. If the caregivers have
wrote about his past therapy and attachment				difficulty engaging with their child in this manner,
therapy this way (More details of this story can				then treatment of the caregiver is indicated.
be found in the book Creating Capacity for				Children who have experienced chronic
Attachment, edited by Arthur Becker-Weidman &				maltreatment and resulting complex trauma are
Deborah Shell):				at significant risk for a variety of other behavioral,
My first therapy was with Dr.Steve. The therapy				neuropsychological, cognitive, emotional,
was FUN!!!! We ate lots of snacks. I had a bottle.				interpersonal, and psychobiological disorders (Cook,
We played lots of cool games like thumb				A., et. al., 2005; van der Kolk, B., 2005). Children
wrestling, pillow rides, giant walk, Superman rides,				and adolescents with complex trauma require an
guess the goodies, eye blinking contests, hide and				approach to treatment that focuses on several
go seek goodies. I had to follow the rules and play				dimensions of impairment (Cook, et. al., 2005).
the games just like Dr. Steve said.				Chronic maltreatment and the resulting complex
Dr. Steve taught me how to play and have fun				trauma cause impairment in a variety of vital
with my Mom. But I still didn't know how to love. I				domains including the following:
would still get real mad and try to hurt Mom and				ÃƒÂ˜ Self-regulation
break things. Inside I still thought I was a bad boy.				ÃƒÂ˜ Interpersonal relating including the
I was still afraid Mom and Dad would get rid of				capacity to trust and secure comfort
me. I had lots of tantrums at home. Sometimes I				ÃƒÂ˜ Attachment
would still get out of control and break things and				ÃƒÂ˜ Biology, resulting in somatization
try to hurt Mom. I was getting even worse when				ÃƒÂ˜ Affect regulation
I got mad.				ÃƒÂ˜ Increased use of defensive
Stuff Dr. Art Taught Me				mechanisms, such as dissociation
I learned about my feeling well. Sometimes I stuff				ÃƒÂ˜ Behavioral control
too many feelings like mad, scared and sad into				ÃƒÂ˜ Cognitive functions, including the
my feeling well. Then the well will overflow and I				regulation of attention, interests, and other
could explode with behaviors. But I can stop that				executive functions.
by expressing my feelings. Then the well can't				ÃƒÂ˜ Self-concept.
overflow because I let some of the feelings out.				Dyadic Developmental Psychotherapy addresses
I also made pictures of my heart. I was born with				these domains of impairment. Dyadic
a nice heart but then when I went into the				Developmental Psychotherapy shares many
orphanage I got cracks in my heart. My heart				important elements with optimal, sound social
cracked because they couldn't take good care of				casework and clinical practice. For example,
me. I was a baby and I needed someone to hold				attention to the dignity of the client, respect for
me and rock me. But they couldn't because there				the client's experiences, and starting where the
were too many babies. Then I put 16 bricks				client is, are all time-honored principles of clinical
around my heart. I was protecting my heart so it				practice and all are also central elements of
wouldn't get hurt anymore. But the bricks kept				Dyadic Developmental Psychotherapy
the love out too. I wouldn't let Mom's love in. I had				In summary, therapy for traumatized children
lots of mad in my heart.				who have disordered attachments must be
My hard work in therapy got rid of all the bricks.				experiential, consensual, and provide an
Then Mom's love got in. The love made the				environment of security, acceptance, safety,
cracks heal. Now I have a bright red heart with				empathy, and playfulness.
no cracks.				[1] Becker-Weidman, A., (2006) "Treatment for
I really liked Dr. Art now and am proud that I am				Children with Trauma-Attachment Disorders:
strong. I still don't need therapy. I still let Mom's				Dyadic Developmental Psychotherapy," Child and
love into my heart!!!!!! Sometimes I send e-mail's to				Adolescent Social Work Journal. Vol. 23 #2, April
Dr. Art. I tell him how good I'm doing.				2006, 147-171.
I started missing Dr. Art and told Mom. Mom was				Becker-Weidman, A., (2006). "Dyadic
confused and thought I wanted more therapy. I				Developmental Psychotherapy: A multi-year
told Mom "I don't need therapy. I just want to				Follow-up," in, New Developments In Child Abuse
have lunch with Dr. Art." So I sent Dr. Art an				Research, Stanley M. Sturt, Ph.D. (Ed.) Nova
email to let him know that I wanted to have lunch				Science Publishers, NY, pp. 43 -- 61.
with him. Then one day we had lunch together.				Becker-Weidman, A., (2007) "Treatment For
Sometimes it's still hard. I still get mad and				Children with Reactive Attachment Disorder:
sometimes I don't express my feelings well.				Dyadic Developmental Psychotherapy,"
Sometimes when Mom helps me ? I can express				Becker-Weidman, A., & Hughes, D., (2008) "Dyadic
my feelings and say "I don't want to pick up my				Developmental Psychotherapy: An evidence-based
toys. It makes me mad that I have to ? but I				treatment for children with complex trauma and
will". When I say that it doesn't make me feel				disorders of attachment," Child & Adolescent
mad anymore. It helps me to listen to Mom. But				Social Work, 13, pp.329-337.
sometimes when I get mad I pout and stomp				Craven, P. & Lee, R. (2006) Therapeutic
my feet and run to my room if I forget to				interventions for foster children: a systematic
express my feelings. But now I let Mom help me				research synthesis. Research on Social Work
so that I can talk about my feelings and do what				Practice, 16, 287-304.
she says				[2] O'Connor, T., & Zeanah, C., (2003) Attachment
It's been a really longtime since I tried to hurt				Disorders: Assessment strategies and treatment
Mom or break things when I'm mad. I feel good				approaches. Attachment & Human Development,
about love now. I know that my Mom and Dad				5, 223-245.
love me. I know that I love Mom and Dad. I don't				[3] Hughes, D., (2008) Attachment-focused Family
feel like I'm a bad boy anymore.				Therapy. NY: Norton.
Effective therapy uses experiences to help a child				[4] Lyons-Ruth, K., & Jacobvitz, D., Attachment
experience safety, security, acceptance,				disorganization: unresolved loss, relational violence
empathy, and emotional attunement within the				and lapses in behavioral and attentional strategies.
family. A number of techniques and methods are				In Cassidy, J. & Shaver, P., (Eds.) Handbook of
used including psychodrama, interventions				Attachment. pp 520-554, NY: Guilford Press, 1999.
congruent with Theraplay, and other exercises.				Solomon, J. & George, C. (Eds.). Attachment
SECOND PRINCIPAL. Therapy must be				Disorganization. NY: Guilford Press, 1999.
family-focused. Therapy helps the child address				Main, M. & Hesse, E. Parents' Unresolved
the underlying trauma in a supportive, safe,				Traumatic Experiences are related to infant
secure environment in "titrated" and manageable				disorganized attachment status. In Greenberg,
doses so that what the parents have to offer				M.T., Ciccehetti, D., & Cummings, E.M. (Eds.)
can get in and heal the child. It is the parents'				Attachment in the Preschool Years: Theory,
capacity to create a safe and nurturing home that				Research, and Intervention, pp.161-182, Chicago:
provides a healing environment. Being able to have				University of Chicago Press, 1990.
empathy for the child, accept the child, love the				Carlson, E.A. (1988). A prospective longitudinal
child, be curious about the child, and be playful are				study of disorganized/disoriented attachment. Child
all part of the "attitude[15]" that heals. Parents are				Development 69, 1107-1128.
actively involved in treatment.				[5] Carlson, V., Cicchetti, D., Barnett, D., &
THIRD PRINCIPAL. The trauma must be directly				Braunwald, K. (1995). Finding order in
addressed. Therapy helps healing by providing the				disorganization: Lessons from research on
safety and security so that the child can				maltreated infants' attachments to their
re-experience the painful and shameful emotions				caregivers. In D. Cicchetti & V. Carlson (Eds), Child
that surround the child's trauma. Revisiting the				Maltreatment: Theory and research on the causes
trauma is essential if the child is to begin to revise				and consequences of child abuse and neglect (pp.
the child's personal narrative and world-view. It is				135-157). NY: Cambridge University Press.
by revisiting the trauma and sharing the anger and				Cicchetti, D., Cummings, E.M., Greenberg, M.T., &
shame with an accepting, empathetic person that				Marvin, R.S. (1990). An organizational perspective
the child can integrate the trauma into a coherent				on attachment beyond infancy. In M. Greenberg,
self.				D. Cicchetti, & M. Cummings (Eds), Attachment in
FOURTH PRINCIPAL. A comprehensive milieu of				the Preschool Years (pp. 3-50). Chicago: University
safety and security must be created.				of Chicago Press.
Traumatized children are often hyper-vigilant,				[6] Robins, L.N. (1978) Longitudinal studies: Sturdy
insecure, and deeply distrusting. A consistent				childhood predictors of adult antisocial behavior.
environment that is safe and secure is essential				Psychological Medicine,. 8, 611-622.
to creating the experiences necessary for the				[7] Prino, C.T. & Peyrot, M. (1994) The effect of
child to heal. This milieu must be present at home				child physical abuse and neglect on aggressive
and in therapy. Good communication and				withdrawn, and prosocial behavior. Child Abuse and
coordination among home, school, and therapy is				Neglect, 18, 871-884.
another important element of effective				[8] Schreiber, R. & Lyddon, W. J. (1998) Parental
treatment. "Compression-wraps," invasive and				bonding and Current Psychological Functioning
intrusive stimulation designed to evoke rage,				Among Childhood Sexual Abuse Survivors. Journal
"re-birthing," and other provocative techniques are				of Counseling Psychology, 45, 358-362.
not part of Dyadic Developmental Psychotherapy.				Ã‚
These intrusive and invasive techniques are not				[9] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A.
therapy, not therapeutic, and have no place in a				(2000). Attachment Styles in Maltreated Children:
reputable treatment program.				A Comparative Study. Child Development and
Fifth Principal. Therapy is consensual and not				Human Development, 31, 113-128.
coercive. At our center we are very clear that				[10] Dozier, M., Stovall, K.C., & Albus, K. (1999)
physical restraint is not treatment and is not used				Attachment and Psychopathology in Adulthood. In
in treatment in any manner. Treatment is				J. Cassidy & P. Shaver (Eds.). Handbook of
provided in a manner consisted with the				Attachment (pp. 497-519). NY: Guilford Press.
Association for the treatment and Training of				[11] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A.
Children's White Paper on Coercion in treatment.				(2000). Attachment Styles in Maltreated Children:
DETAILED DESCRIPTION OF TREATMENT				A Comparative Study. Child Development and
Dyadic Developmental Psychotherapy is a				Human Development, 31, 113-128.
treatment developed by Daniel Hughes, Ph.D.,				Ã‚
(Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its				[12] Allan, J. (2001). Traumatic Relationships and
basic principals are described by Hughes and				Serious Mental Disorders. NY: John Wiley.
summarized as follows:				Andrews, B., Varewin, C.R., Rose, S., & Kirk
1. A focus on both the caregivers and therapists				(2000). Predicting PTSD symptoms in Victims of
own attachment strategies. Previous research				Violent Crime. Journal of Abnormal Psychology,
(Dozier, 2001, Tyrell 1999) has shown the				109, 69-73.
importance of the caregivers and therapists state				Ã‚
of mind for the success of interventions.				[13] MacMillian, H.L. (2001). Childhood Abuse and
2. Therapist and caregiver are attuned to the				Lifetime Psychopathology in a Community Sample.
child's subjective experience and reflect this back				American Journal of Psychiatry, 158, 1878-1883.
to the child. In the process of maintaining an				Ã‚
intersubjective attuned connection with the child,				[14] Allan, J. Traumatic Relationships and Serious
the therapist and caregiver help the child regulate				Mental Disorders, NY: Wiley, 2001.
affect and construct a coherent autobiographical				Andrews, B., Varewin, C.R., Rose, S. & Kirk.
narrative.				Predicting PTSD symptoms in Victims of Violent
3. Sharing of subjective experiences.				Crime. Journal of Abnormal Psychology, vol. 109,
4. Use of PACE and PLACE are essential to				69-73, 2000.
healing.				Ã‚
5. Directly address the inevitable misattunements				[15] Hughes, D., (2007) Building the Bonds of
and conflicts that arise in interpersonal				Attachment, 2nd. Edition, NY: Guilford Press.

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Dyadic Developmental Psychotherapy: an Evidence-based Treatment for Disorders of Attachment; the Empirical Support