Dyadic Developmental Psychotherapy - An Evidence-Based Treatment For Disorders of Attachment

Dyadic Developmental Psychotherapy is an evidence-based and effective form of treatment for children with trauma and disorders of attachment . It is an evidence-based treatment, meaning that there has been empirical research published in peer-reviewed journals. Craven & Lee (2006) determined that DDP is a supported and acceptable treatment (category 3 in a six level system). However, their review only included results from a partial preliminary presentation of an ongoing follow-up study, which was subsequently completed and published in 2006. This initial study compared the results DDP with other forms of treatment, 'usual care', 1 year after treatment ended.

It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment mean a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in DDP being classified as an evidence-based category 2, 'Supported and probably efficacious'. There have been two related empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

1. The treatment has a sound theoretical basis in generally accepted psychological principles. Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below

2. A substantial clinical, anecdotal literature exists indicating the treatment's efficacy with at-risk children and foster children. See reference list.

3. The treatment is generally accepted in clinical practice for at risk children and foster children. As demonstrated by the large number of practitioners of Dyadic Developmental Psychotherapy and it's presentation as numerous international and national conferences over the last ten or fifteen years.

4. There is no clinical or empirical evidence or theoretical basis indicating - that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

5. The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation. Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.

6. At least two studies utilizing some form of control without randomization (e.g., wait list, untreated group, placebo group) have established the treatment's efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already established treatment. See ref. list.

7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supported the efficacy of the treatment.

These studies support several of O'Connor & Zeanah's conclusions and recommendations concerning treatment. They state (p. 241), "treatments for children with attachment disorders should be promoted only when they are evidence-based."

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment .

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first few years of life. These experiences disrupt the normal attachment process so that the child's capacity to form a healthy and secure attachment with a caregiver is distorted or absent. The child lacks a sense trust, safety, and security. The child develops a negative working model of the world in which:

- Adults are experienced as inconsistent or hurtful.

- The world is viewed as chaotic.

- The child experiences no effective influence on the world.

- The child attempts to rely only on him/her self.

- The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems and even Psychotic Disorder symptoms are often seen in children with disorganized attachment.

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms . Many of these children are violent and aggressive and as adults are at risk of developing a variety of psychological problems and personality disorders, including antisocial personality disorder , narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder . Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence . Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults . Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average) (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults .

FIRST PRINCIPAL. Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are one "active ingredient" in the healing process.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way (More details of this story can be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My first therapy was with Dr. Steve. The therapy was FUN! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn't know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me - I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can't overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn't take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn't because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn't get hurt anymore. But the bricks kept the love out too. I wouldn't let Mom's love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom's love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don't need therapy. I still let Mom's love into my heart! Sometimes I send e-mail's to Dr. Art. I tell him how good I'm doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom "I don't need therapy. I just want to have lunch with Dr. Art." So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it's still hard. I still get mad and sometimes I don't express my feelings well. Sometimes when Mom helps me I can express my feelings and say "I don't want to pick up my toys. It makes me mad that I have to but I will". When I say that it doesn't make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It's been a really longtime since I tried to hurt Mom or break things when I'm mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don't feel like I'm a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement within the family. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy must be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in "titrated" and manageable doses so that what the parents have to offer can get in and heal the child. It is the parents' capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the "attitude " that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child's trauma. Revisiting the trauma is essential if the child is to begin to revise the child's personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. "Compression-wraps," invasive and intrusive stimulation designed to evoke rage, "re-birthing," and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not used in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children's White Paper on Coercion in treatment.

The therapist must be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh. In selecting a therapist you should look for the following:

- Significant training from a recognized training program. Ask where the therapist was trained, how long ago, and for how long.

- Ongoing training. Ask when was the last training event the therapist attended and how long was the event.

- Licensure in the state in a recognized mental health discipline.

- Membership in ATTACh.

- A comprehensive informed consent document and appropriate releases.

- An initial assessment to develop a differential diagnosis and treatment plan.

DETAILED DESCRIPTION OF TREATMENT

Dyadic Developmental Psychotherapy is a treatment developed by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. Therapist and caregiver are attuned to the child's subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.

3. Sharing of subjective experiences.

4. Use of PACE and PLACE are essential to healing.

5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

6. Caregivers use attachment-facilitating interventions.

7. Use of a variety of interventions, including cognitive-behavioral strategies.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the necessity for sensitive care-giving. As O'Connor & Zeanah (2003, p. 235) have stated, "A more puzzling case is that of an adoptive/foster caregiver who is 'adequately' sensitive but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in already sensitive parent) would yield positive changes in the parent-child relationship." Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another part of the foundation on which Dyadic Developmental Psychotherapy rests.

The primary approach is to create a secure base in treatment (using techniques that fit with maintaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principals that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned relationship within which contingent collaborative communication occurs helps the child heal. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an emotional response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never used and are inconsistent with a treatment rooted in attachment theory and current knowledge about the neurobiology of interpersonal behavior.

Dyadic Developmental Psychotherapy, as conducted at The Center For Family Development, uses two-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the caregivers are in the treatment room, the caregivers are viewing treatment from another room by closed circuit T.V. or a one-way mirror. The usual structure of a session involves three components. First, the therapist meets with the caregivers in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman & Shell (2005) Hughes, 2006). The caregiver's own issues that may create difficulties with developing affective attunement with their child may also be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this part of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child. Second, the therapist with the caregivers meets with the child in the treatment room. This generally takes one to one and a half hours. Third, the therapist meets with the caregivers without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude.

Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children. Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma. This affective attunement is the same process used for non-verbal communication between a caregiver and child during attachment facilitating interactions (Hughes, 2003, Siegel, 2001). The therapist and caregivers' attunement results in co-regulation of the child's affect so that is it manageable. Cognitive restructuring interventions are designed to help the child develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative. Treatment involves multiple repetitions of the fundamental caregiver-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the relationship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are essential elements to creating affective attunement.

The treatment provided often adhered to a structure with several dimensions. It is pictured in Figure 1, below. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore and the meaning to the child begins to emerge. Third, empathy is used to reduce the child's sense of shame and increase the child's sense of being accepted and understood. Forth, the child's behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn't want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.

Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the behavior is found and the child's actions are integrated into a coherent autobiographical narrative by communicating the new experience and meaning to the caregiver.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child's behavioral disturbances. The child develops secondary representations of these events, feelings and thoughts that result in greater affect regulation and a more integrated autobiographical narrative.

As described by Hughes (2006, 2003), the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child's emerging affective states and developing secondary representations of thoughts and feelings, the child's capacity to affectively engage in a trusting relationship is enhanced. The caregivers enact these same principals. If the caregivers have difficulty engaging with their child in this manner, then treatment of the caregiver is indicated.

Children who have experienced chronic maltreatment and resulting complex trauma are at significant risk for a variety of other behavioral, neuropsychological, cognitive, emotional, interpersonal, and psychobiological disorders (Cook, A., et. al., 2005; van der Kolk, B., 2005). Children and adolescents with complex trauma require an approach to treatment that focuses on several dimensions of impairment (Cook, et. al., 2005). Chronic maltreatment and the resulting complex trauma cause impairment in a variety of vital domains including the following:

- Self-regulation

- Interpersonal relating including the capacity to trust and secure comfort

- Attachment

- Biology, resulting in somatization

- Affect regulation

- Increased use of defensive mechanisms, such as dissociation

- Behavioral control

- Cognitive functions, including the regulation of attention, interests, and other executive functions.

- Self-concept.

Dyadic Developmental Psychotherapy addresses these domains of impairment. Dyadic Developmental Psychotherapy shares many important elements with optimal, sound social casework and clinical practice. For example, attention to the dignity of the client, respect for the client's experiences, and starting where the client is, are all time-honored principles of clinical practice and all are also central elements of Dyadic Developmental Psychotherapy

In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness. Only an experienced and trained therapist can provide attachment therapy.

Becker-Weidman, A., (2006) "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy," Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 147-171.
Becker-Weidman, A., (2006). "Dyadic Developmental Psychotherapy: A multi-year Follow-up," in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43 -- 61.
Becker-Weidman, A., (2007) "Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy," http://www.center4familydevelop.com/research.pdf
Becker-Weidman, A., & Hughes, D., (2008) "Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment," Child & Adolescent Social Work, 13, pp.329-337.
Craven, P. & Lee, R. (2006) Therapeutic interventions for foster children: a systematic research synthesis. Research on Social Work Practice, 16, 287-304.

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Mindfulness Psychotherapy For Post-Traumatic Stress Disorder

Post-traumatic Stress Disorder (PTSD) first came to the attention of doctors during the First World War when relatively large numbers of soldiers returned from combat exhibiting intense emotional distress in which they seemed to re-live the terrifying events of war long after the event. However, war is only one context in which PTSD arises. Later, it became clear that this phenomenon of delayed emotional reactivity could result from many other contexts such as accidents and illness, physical assault, rape or witnessing acts of violence and devastation, natural or man-made. Childhood abuse is now recognized as one of the major sources of PTSD.

In general PTSD can be defined as severe recurrent emotional anxiety reactions that originate from an intense and traumatic experience. A trauma occurs when there is a combination of sensory and emotional overload that cannot be processed and integrated into the psyche. A war scenario provides many intense visual, auditory and contextual stimuli that are completely foreign to the average person, as does sexual abuse, rape or witnessing a car accident. Context plays a very important part as in the case of childhood abuse, where the child's model of how his parents should behave cannot be reconciled with the parent's actual behavior. The experience of intense fear that accompanies trauma becomes encoded into the internal memory imprint of the associated sensory experiences. The unprocessed sensory experiences and associated emotional reactivity become submerged and repressed in the subconscious mind as a core emotional complex. When the appropriate stressors are present or when the suppressive activities of the ego are weakened, as is the case during sleep this repressed emotional complex is activated leading to a repeat experience of the emotional trauma, often with the associated visual imagery in the form of flashbacks. Like other core emotional complexes, the repression is never complete and negative emotional energy leaks into present experience leading to general anxiety, phobias, recurrent anger, sleep difficulties, depression, obsessive-compulsive behaviours and substance abuse. These can be described as the layers of secondary reactivity that form around the primary trauma reaction and which, in their own way, shield the core emotional complex from further processing and integration by the psyche.

There are many approaches to treating PTSD, some involving medication and others focussed on psychotherapy. Cognitive Behavioral Therapy (CBT) is a particularly useful approach, because it focuses on the client's actual patterns of habitual negative thinking and beliefs and attempts to change these into more positive and functional forms. The form of cognitive therapy described in this article is called Mindfulness Meditation Therapy (MMT), which can be defined as the direct application of mindfulness to an emotional complex to facilitate transformation and resolution. Mindfulness describes a particular form of awareness that is present-centered, direct and non-reactive towards an object of awareness. It is best described as the combination of PRESENCE and INVESTIGATION in which there is an openness of mind and heart to fully experience and know what is present in our field of awareness. Presence is one of the most important components of sensitive listening as when we are listening to a friend who is suffering. As we know from experience, simply being there with him or her in this way with complete attention and presence is often more important than what we say or do. In this same way, learning to be fully present for our emotional suffering is highly therapeutic and is perhaps one of the major contributions to the healing process. The other aspect of mindfulness is simply learning to recognize all the patterns of habitual reactivity that takes us away from being fully present for our emotional suffering. Meditation in the context of MMT refers to the direct application of mindfulness and presence to the emotional suffering itself, which becomes the object of our meditation. In general, during MMT, we allow the emotional complex to unfold and differentiate into more and more subtle content. This differentiation into specific feelings, memories and sensory content leads to direct transformation of emotional complexes and literally makes the complex easier to digest.

Traumatic memories have a specific internal structure in the form of intense imagery. This imagery may be photographic in quality, revealing the actual memory of the traumatic event, but more often it also includes abstract elements of color, shape and movement in something resembling a surrealistic collage. Whatever the form of the imagery, this internal representation is an essential part of what is required to produce intense emotional reactions. This is referred to as the Structural Theory of Emotions, where emotional energy is encoded in the specific sub-modalities of size, color, intensity, movement and texture. An intense emotion is likely to be encoded in intense colors such as red and orange and the imagery is likely to be large and close in the person's inner visual field, whereas neutral emotions are likely encoded in neutral colors such as pale blue or white and appear small and far away. It is by becoming aware of this internal structure of the imagery that encodes the emotional energy of the trauma that we can explore the possibility of changing the imagery and thus changing the emotional intensity of a traumatic memory. This concept is developed to an art in the therapeutic modality called Neuro-Linguistic Programming, or NLP. Just as language is made of words that represent internal experience, imagery represents the natural language of the mind - the mind thinks in pictures and uses inner imagery to organize experience and memory.

The Structural Theory of Emotions proposes that by changing the structure of the imagery it is possible to change the intensity of the emotional reaction. Thus, if the color changes from intense red to soft yellow and the imagery becomes smaller and further away, it is very likely that the emotion will be much less intense. However, for this to work effectively the imagery must arise experientially from the emotional felt sense, rather than be created through deliberate visualization. Similarly, the direction of change must arise experientially, rather than be imposed externally. In this way, the client maintains close presence with his inner experience and knows that what happens is meaningful and relevant to his or her specific transformational process. This is why mindfulness is such an important part of the transformational process, because it allows us to be exquisitely sensitive to what is meaningful and what is not. The investigative dimension of mindfulness also provides the best approach to uncover the detailed inner structure of the emotion and provide meaningful content.

A central focus in MMT is to uncover this internal structure of the traumatic memory and then to investigate this experiential content. There is no attempt to interpret what arises, only to experience fully and know completely whatever arises. This process essentially de-constructs the emotional complex into smaller parts that the psyche can digest and integrate into more stable configurations that do not continue to generate emotional suffering. Of course, this requires considerable preliminary preparation so that the client can experience the internal imagery without becoming overwhelmed by it. This preliminary phase of MMT is focussed on establishing the Mindfulness Based Relationship (MBR) in which there is sufficient stability and non-reactivity to allow the imagery to unfold into present awareness. There are many approaches to achieve the right MBR, such as watching the imagery as if projected on a screen or placing the imagery at some distance in front. Through mindfulness and careful investigation, the client can discover for himself what works best for establishing the MBR. However, once a client begins to witness specific details about the imagery, he inevitably finds it much easier to establish the MBR, because the specific content gives him a specific focus and this tends to prevent hyper-reactivity. The MBR is an essential part of the transformation process for many reasons, the primary reason being that it allows the compacted emotional complex to unfold into more manageable parts. At another level, the MBR allows the client to fundamentally change the way that he relates to his inner emotional experience and he begins to break free from seeing himself as a victim of the emotional trauma. This in itself is an essential requirement for change.

Throughout the whole process of Mindfulness Meditation Therapy, as developed by Dr Peter Strong, of Boulder, Colorado, the client is repeatedly exposed to the source of his fear, but in new ways that don't involve being overwhelmed. This exposure desensitization effect is regarded by most schools of psychotherapy as an essential part of overcoming PTSD and Mindfulness Meditation Therapy provides a very subtle and specific way of doing this. However, the heart of the transformational process occurs as the mind begins to make subtle changes in the core experiential imagery at the core of post-traumatic stress. The client discovers ways to change this imagery, and some suggestions are also made by the therapist. Through a process of creative exploration, the client transforms this inner imagery and the effect of this is to transform the PTSD. Trauma becomes reduced into a form that can be assimilated as a memory and ceases to produce recurrent anxiety.

Peter Strong, PhD is a scientist and Buddhist psychotherapist, based in Boulder, Colorado, who specializes in the study of mindfulness and its application in Mindfulness Meditation Therapy. He teaches mindfulness meditation (vipassana) and works with individuals and couples using Mindfulness Meditation Therapy for resolving difficult emotional problems, including anxiety, depression, phobias, grief and trauma and the management of anger and stress.

Besides face-to-face work, Peter also works with individuals and couples online via SKYPE. For Online Counseling, visit http://www.counselingtherapyonline.com

To learn more about Mindfulness Therapy, visit http://www.mindfulnessmeditationtherapy.com
Email inquiries welcome.

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