Jul 28, 2009

Therapeutic Parent Manual

The new Parent Manual, put out by the Association for the Treatment and Training in the Attachment of Children, is a wonderful resource for parents. It has a wealth of information and practical suggestions.

It covers many issues that children with Complex Trauma and disorders of attachment face.

copies can be ordered on Amazon.com or at www.attach.org

Jul 24, 2009

Complex Trauma

Complex Post Traumatic Stress Disorder: Definition, Assessment, Treatment.
Arthur Becker-Weidman, Ph.D.,

Complex Post Traumatic Stress Disorder (CPTSD) is a clinical formulation (which may be included in the proposed DSM-V expected out in 2011) that refers to the results or outcomes of four simultaneous factors:
1. Chronic
2. Early
3. Maltreatment
4. Within a care-giving relationship
Maltreatment refers to abuse or neglect. Early, meaning occurring in early childhood; within the first several years of life. Chronic meaning a pervasive pattern, no a single or discrete event. Very important is that all the above occurs within a care-giving relationship. It is this last factor that makes the chronic early maltreatment so insidious and that leads to such pervasive negatives effects on later development and impairment in so many domains of functioning.
The domains of impairment include the following:
1. Attachment
2. Biology
3. Emotional regulation
4. Dissociation
5. Behavioral control
6. Cognition
7. Self-concept
As a result of pervasive impairment, assessment must be multi-modal and comprehensive in nature. This is important since “symptoms,” can have many causes and it is the cause that is the primary focus of treatment not the surface symptom. For example, anxiety can be caused by an anxiety disorder, brain trauma, PTSD, or various medical conditions. A comprehensive assessment of a child who has CPTSD must include, at a minimum, a review of all previous records, clinical sessions with the parents and with the child, and the use of various psychometric instruments to screen for a variety of issues. The areas that a through assessment must cover include: mental health differential diagnosis, sensory-integration screening, a screening for neuro-psychological issues, screening for executive function problems, attachment, developmental screening, consideration of Alcohol Related Neurological Dysfunction (ARND), and consideration of the nature and quality of the family’s interpersonal, emotional, and psychological constellation.
Children and adolescents with complex trauma require a multimodal approach (Cook, et. al., 2005), (Cook, Blaustein, Spinazzola, van der Kolk, 2003, Cook, Spinazzola, Ford, Lanktree, et. al., 2005). These authors identify six core components of complex trauma interventions, which are the following: “safety, self-regulation, self-reflective information processing, traumatic experience integration, relational engagement, and positive affect enhancement” (Cook, Spinazzola, Ford, Lanktree, et. al, 2005 p. 395).
Safety, actual safety and the client’s perception of safety, is vital for the creation of a secure base and a healthy attachment. At a minimum this must include the absence of physical danger, emotional and psychological maltreatment, and other threats to the physical, emotional, psychological, and interpersonal integrity of the child. One aspect of this includes creating an environment in therapy and at home in which coercive and shaming interactions are reduced and eliminated (Becker-Weidman, 2005).
Self-regulation is achieved in treatment by focusing on helping develop and enhance the capacity to modulate arousal in a variety of domains such as emotional, behavioral, physiological, and interpersonally. Children who have experienced chronic maltreatment and complex trauma have difficulty with self-regulation, especially with affect regulation. They can become dysregulated quite easily. The co-regulation of affective states through experiences of parent-infant attunement necessarily precedes the ability to self-regulate such states (Schore, 2001). Such attunement experiences were very infrequent for most of these children. In one relevant approach, Dyadic Developmental Psychotherapy, the practitioner expends a considerable amount of attention and energy to dyadically regulating the child’s level of arousal much like the responsive and attuned parent does (Hughes, 2007). The therapist functions to maintain a “therapeutic window” (Briere & Scott, 2006). The therapist actively works to avoid either inadequate or overwhelming activation of affect during treatment. If dysregulation occurs, the therapist acts swiftly to re-regulate the child, repair the relationship, and achieve emotional safety and balance.
Self-reflective information processing is achieved in treatment by developing and maintaining the shared affect, attention, and intentions that characterize intersubjectivity (Hughes, 2007). Through these intersubjective experiences the therapist and caregiver assist the child in exploring past events again so that the experience of them can be reorganized. With these additional perspectives of the event, the child is much more able to reflect on it with new meaning and less terror and shame.
Traumatic experience integration can be achieved in treatment by using such techniques as the judicious use of psychodramatic re-enactments, role-playing, and the reading of relevant historical documents such as police reports (Becker-Weidman, 2006). Again, these interventions are only employed within the intersubjective context, with the need for psychological safety remaining primary.
Relational engagement is achieved in treatment by its emphasis on acceptance and by developing and maintaining a therapeutic alliance with all family members. The child’s frequent avoidant or controlling behavioral patterns are likely to decrease when these are also met with acceptance. These defensive patterns are understood as viable coping strategies when the child has not been able to turn to attachment figures for safety. Engaging the child in a reparative relationship therapeutically and at home is an important dimension of complex trauma treatment.
Positive affect enhancement is achieved in treatment by the playful attitude of the therapist. In addition, the therapist’s acceptance of the caregiver’s and child’s feelings and motives and the development of a deep level of empathy enhances self-worth. The positive regard with which the practitioner of Dyadic Developmental Psychotherapy holds the family underscores their intrinsic worth as valued and valuable, as loved and loveable individuals (Becker-Weidman & Shell, 2005), (Hughes, 2007).

Becker-Weidman, A. (2005). Dyadic Developmental Psychotherapy: the theory. In A. Becker-Weidman & D. Shell (Eds.), Creating capacity for attachment (pp. 7-43). Oklahoma City, OK: Wood ‘N’ Barnes.
Becker-Weidman, A. & Shell, D. (Eds.) (2005). Creating capacity for attachment (pp. 7-43). Oklahoma City, OK: Wood ‘N’ Barnes.
Becker-Weidman, A., (2006 c). Treatment for children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy. Child and Adolescent Mental Health, Online electronic version, 11/21/2006, doi: 10.1111/j.1475-3588.2006.00428.x
Briere, J., & Scott, C. (2006) Principles of trauma therapy. NY: Sage.
Cook, A., Blaustein, M., Spinazolla, J., van der Kolk, B. (2003) Complex trauma in children and adolescents. White paper from the national child traumatic stress network complex trauma task force. Los Angeles, CA: National Center for Child Traumatic Stress.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et. al. (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35:5, 390-398.
Hughes, D., (2007), Attachment-Focused Family Therapy. NY: Norton.
Schore, A.N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22, 201-269.

Jul 18, 2009

Master Class in Dyadic Developmental Psychotherapy

A new Master Class for Therapists is planned for 2010.
This class is designed to teach therapists how to provide Dyadic Developmental Psychotherapy, which is an evidence-based, effective, and empirically validated treatment.


Dyadic Developmental Therapy
(An attachment-based therapy)

Training for Therapists in the Treatment of Children with Trauma-Attachment Problems


This workshop is for professionals who have a working knowledge of attachment, how it develops, how attachment disorders develop, and a general knowledge of treatment principals and attachment theory.

Early deprivation, neglect, abuse, significant early health problems and hospitalizations, repeated moves, or more than one year in an orphanage can create attachment problems that require specialized treatment. Traditional forms of therapy are ineffective with attachment-disordered children. This workshop will provide the therapist and other professionals with an opportunity to learn and practice effective treatment methods for trauma-attachment disordered children.

Participants are encouraged to bring in videotapes of sessions or to make arrangements to have a family attend a session for a consultation with the therapist and Dr. Becker-Weidman. .

Dyadic Developmental Psychotherapy is an evidence-based treatment, effective, and empirically validated treatment that is grounded in current thinking and research on the etiology and treatment of Complex Trauma or Developmental Trauma Disorder. Treatment had an educational dimension, designed to help parents understand their child’s attachment disorder: how the child feels and thinks, and the child’s internal psychological dynamics. Second, teaching parents about attachment-facilitating parenting methods and the importance of attunement and responsive, sensitive parenting is essential. Direct work with the parents regarding their own family or origin issues is another componen5t of treatment. Finally, intensive emotional work with the child in a manner consistent with sound treatment principles is vital.

The workshop is led by Dr. Arthur Becker-Weidman, who is certified by the Dyadic Developmental Psychotherapy Institute as a certified Dyadic Developmental Psychotherapist, Certified Consultant, and Certified Trainer. This workshop provides training hours that may be used by the participant to meet the required training hours necessary to become a Certified Dyadic Developmental Psychotherapist.

Purpose of Workshop

This workshop is for therapists who want to learn how to treat trauma-attachment disordered children. Participants will learn effective therapy principals for helping traumatized children. Participants will learn:

Initial assessment and treatment planning.

Beginning, middle, and ending phase interventions.

Developing attunement and maintaining attunement.

Practical implications of the relationship between neurobiology and attachment.

Effective therapeutic techniques to use with traumatized and attachment disordered children.

Effective parenting principals.

Participants will have the opportunity to view videotapes of actual therapy sessions with traumatized children that demonstrate therapeutic principals, present their own video tapes or bring in a client for a consultation, and view live therapy sessions.


A Six-month 42-hour Master Class.
10:00 am – 5:00 pm, March 27 – August 28, 2010 (3/27, 4/24, 5/22, 6/26, 7/24, 8/28). The schedule may be adjusted if all the participants agree, so contact the office for the most current schedule. Limited to 7 professionals.


Evaluation & parenting preparation.
First session, beginnings, attunement, and managing resistance.
Neurobiology of interpersonal experience
Middle phase issues & psychodrama
Facilitating parent-child attachment
Complex Post Traumatic Stress Disorder.
Ending phase issues.

The treatment presented has demonstrated effectiveness. A follow-up study (see our website) clinically and statistically significant reductions in symptoms of attachment disorder, aggression, anti-social behavior, thought disorders, attention problems, mood, and social relationship dysfunction. Over 80% of the children treated had previously been in treatment on three or more occasions, without any noticeable improvement. Dyadic Developmental Psychotherapy produced measurable and stable improvements. Treatment averaged 23 sessions over approximately ten months. (Arthur Becker-Weidman, Ph.D., Child & Adolescent Social Work, vol. 23, pp.137-171, 2006)

Click here for the brochure. http://www.center4familydevelop.com/2010MasterClass.pdf

Jul 6, 2009

Orphan: boycott

The bad press this movie is getting is heating up as more and more adoption groups and outraged parents voice their objections to this movie.

I encourage people to contact Warner Brothers. More to the point, I encourage you to contact your local theater and request that they do not screen the movie. Getting many people to contact the theater and to state that you will not attend that theater as long as that movie is showing may get them to not screen the film.

Editorials in the local paper would also help.

Jul 5, 2009

Orphan: A movie to boycott

Warner Brothers is releasing a movie that is already evoking serious concern among adoption groups, mental health professionals, and others in the child welfare system. "Orphan" presents the story of an adopted child who is "damaged goods" and is violent and aggressive toward her adoptive family while appearing sweet and innocent to others. She is presented as a calculating, cunning child whose intention is to hurt her new family.

Children with complex trauma or disorders of attachment may be aggressive, violent, and difficult to live with. However their behavior is usually grounded in fear. Their early experiences may have "taught" them that relationships and intimacy are to be feared and avoided because these are inconsistent, painful, and not helpful.

This movie is a grounded in the myth that adopted children are emotionally disturbed because of "bad genes," and so there is not hope. Nothing could be further from the truth. See: "Brown University Child and Adolescent Behavior Letter" (Demick, K.( 2007) "Challenging the common myths about adoption". Vol. 23 (4), p. 8).

Complex trauma often results in impairment in several domains and must be treated with effective, evidence-based, and empirically validated treatments, such a Dyadic Developmental Psychotherapy. How long the child has experienced maltreatment is a major factor in outcome. In addition, the adoptive parent's understanding of the early trauma and how that effects later behavior is also key to a good outcome. For older children "usual" or "automatic" parenting is usually not good enough and some form of therapeutic parenting is necessary (see Creating Capacity for Attachment edited by Arthur Becker-Weidman & Deborah Shell). The research is clear that the factors associated with "placement stability," include the caregiver's commitment, sensitivity, insightfulness, and state of mind with respect to attachment.

This film sends the wrong message. It is also based on incorrect data and information regarding the effects of early trauma on child development and what parents can do.

Boycott this film.

Jul 4, 2009

The Boy Who Was Raised as a Dog

The Boy Who was Raised as a Dog by Bruce Perry & Maia Szalavitz, Basic Books, NY, 2006.

This terrifically engaging and readable book can be thought of as the case-book companion to Dr. Daniel Siegel’s The Developing Mind. Dr. Perry and Ms. Szalavitz, an award winning writer, present eleven stories, hence the subtitle: “And other stories from a Child Psychiatrist’s Notebook. What traumatized children can teach us about loss, love, and healing.” In this book each story describes a child’s trauma, how this affected the child, and what could be done about that. Much of what Dr. Perry presents may not be new, but the manner in which his insights are woven into these stories is wonderful. A major theme is how early maltreatment dysregulates the stress-response system and how this state eventually becomes a trait. He peppers the book with some very interesting tidbits…such as that many children who have experienced chronic early trauma have elevated resting heart rates. This is one of those things that, after reading, I said, Oh, I think I new that, but never really thought about it. (BTW, this helps explain why and how the blood pressure medication, Clonadine can sometimes be helpful for children who experience Complex Post Traumatic Stress Disorder.) When I began asking the families I see to take the pulse of their children while the child was asleep, a large percentage (over half!) reported resting pulse rates of over 110 bpm.

The book emphasizes and underscores the power of relationships to wound and heal. “To calm a frightened child, you must first calm yourself.” This simple and profound statement is echoed throughout the book and can be considered one of the cornerstones of good parenting and treatment. In another section of the book, “The Coldest Heart,” he describes how many traumatized children have a large split between verbal and performance scores and how this reflects imbalances in the brain’s capacity to modulate affect. Although this, and other insights, may seem esoteric, it is the way these insights are woven into very touching stories that make the material memorable and usable.

Each story is both delightful and horrifying to read. Dr. Perry’s compassion and insights are models of how a therapist should act. The stories include the Branch Davidian children and some other famous cases. This is a must read book that should be in every clinician’s bookcase. I have also begun recommending it to parents, who are finding the insights presented very helpful in understanding their child and developing better ways of managing their own feelings.