Behavioral therapy for children methods. Cognitive Behavioral Psychotherapy

Cognitive Behavioral Therapy was born out of two popular methods in psychotherapy in the second half of the 20th century. These are cognitive (thought change) and behavioral (behavior modification) therapy. Today, CBT is one of the most studied therapies in this field of medicine, has undergone many official trials and is actively used by doctors around the world.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a popular method of treatment in psychotherapy based on the correction of thoughts, feelings, emotions and behavior, designed to improve the quality of life of the patient and rid him of addictions or addictions. psychological disorders.

In modern psychotherapy, CBT is used to treat neurosis, phobias, depression and other mental problems. And also - to get rid of any type of addiction, including drugs.

CBT is based on simple principle. Any situation first forms a thought, then comes an emotional experience, which results in a specific behavior. If the behavior is negative (for example, taking psychotropic drugs), then you can change it if you change the way you think and emotional attitude person to the situation that caused such a detrimental reaction.

Cognitive Behavioral Therapy is relatively short technique, usually it lasts 12-14 weeks. Such treatment is used at the stage of rehabilitation therapy, when the intoxication of the body has already been carried out, the patient has received the necessary medication, and the period of work with a psychotherapist begins.

The essence of the method

From a CBT perspective, drug addiction consists of a series of specific models behaviors:

• imitation (“friends smoked / sniffed / injected, and I want to”) - actual modeling;
• based on personal positive experience from taking drugs (euphoria, avoiding pain, increasing self-esteem, etc.) - operant conditioning;
• coming from the desire to experience pleasant sensations and emotions again - classical conditioning.

Scheme of impact on the patient during treatment

In addition, a person’s thoughts and emotions can be affected by a number of conditions that “fix” addiction:

• social (conflicts with parents, friends, etc.);
• the influence of the environment (TV, books, etc.);
• emotional (depression, neurosis, desire to relieve stress);
• cognitive (the desire to get rid of negative thoughts, etc.);
• physiological (unbearable pain, "breaking", etc.).

When working with a patient, it is very important to determine the group of prerequisites that affected him specifically. If you form other psychological attitudes, teach a person to react to the same situations in a different way, you can get rid of drug addiction.

CBT always begins with the establishment of contact between the doctor and the patient and the functional analysis of dependence. The doctor must determine what exactly makes a person turn to drugs in order to work with these reasons in the future.

Then you need to set triggers - these are conditioned signals that a person associates with drugs. They can be external (friends, dealers, the specific place where the consumption takes place, the time - Friday night for stress relief, etc.). As well as internal (anger, boredom, excitement, fatigue).

To identify them, a special exercise is used - the patient must write down his thoughts and emotions in the following table for several days, indicating the date and date:

Subsequently, apply various techniques development of personal skills and interpersonal relationships. The former include stress and anger management techniques, various ways to take leisure time, etc. Teaching interpersonal relationships helps to resist the pressure of acquaintances (an offer to use a drug), teaches you to deal with criticism, re-interact with people, etc.

The technique of understanding and overcoming drug hunger is also used, the skills of refusing drugs and preventing relapse are being developed.

Indications and stages of CPT

Cognitive-behavioral therapy has long been successfully used all over the world, it is an almost universal technique that can help in overcoming various life difficulties. Therefore, most psychotherapists are convinced that such treatment is suitable for absolutely everyone.

However, for treatment with CBT there is an essential condition - the patient himself must realize that he suffers from a harmful addiction, and make a decision to fight drug addiction on his own. For people who are prone to introspection, accustomed to monitoring their thoughts and feelings, such therapy will have the greatest effect.

In some cases, before the start of CBT, it is required to develop skills and techniques for overcoming difficult life situations (if a person is not used to coping with difficulties on his own). This will improve the quality of future treatment.

There are many different methods within the framework of cognitive behavioral therapy- in various clinics special techniques may be used.

Any CBT always consists of three consecutive stages:

1. Logical analysis. Here the patient analyzes his own thoughts and feelings, mistakes are revealed that lead to an incorrect assessment of the situation and incorrect behavior. That is, the use of illegal drugs.
2. empirical analysis. The patient learns to distinguish objective reality from perceived reality, analyzes his own thoughts and behaviors in accordance with objective reality.
3. pragmatic analysis. The patient determines alternative ways response to the situation, learns to form new attitudes and use them in life.

Efficiency

The uniqueness of the methods of cognitive-behavioral therapy is that they involve the most active participation of the patient himself, continuous introspection, his own (and not imposed from the outside) work on mistakes. CBT may occur in different forms- individual, alone with the doctor, and group - perfectly combined with the use of medications.

In the process of working to get rid of drug addiction, CBT leads to the following effects:

• provides a stable psychological state;
• eliminates (or significantly reduces) the signs of a psychological disorder;
• significantly increases the benefits of drug treatment;
• improves the social adaptation of a former drug addict;
• reduces the risk of breakdowns in the future.

As studies have shown, best results CBT shows in treatment. Methods of cognitive-behavioral therapy are also widely used in getting rid of cocaine addiction.

22. General principles and methods of behavioral therapy. The system of behavioral psychotherapy by J. Wolpe

Behavioral psychotherapy is a direction in psychotherapy based on the principles of behaviorism.

Principles:

The postulate of behavior therapy is the idea that patterns of behavior play a decisive role in the development of psychological disorders. The "principle of minimal intrusion" postulates that in behavior therapy one should interfere in the patient's internal life only to the extent necessary to solve his actual problems .

Methods:

1. Systematic desensitization. The client is taught relaxation and then asked to imagine an organized sequence of anxiety situations.

2. Playing out in vivo. The client is actually placed in a situation

3. Flooding. A client who has a phobia should dive into that phobia, or rather into a situation that triggers the phobia with no chance of escape.

4. Modeling. The process in which the client learns certain forms of behavior by observing and imitating others; often combined with behavior rehearsal (particularly confidence training)

Psychotherapy with systematic desensitization - a form of behavioral psychotherapy that serves the purpose of reducing emotional susceptibility in relation to certain situations. Developed J. Wolpe based on the experiments of I.P. Pavlov by classical conditioning. According to Wolpe, the inhibition of fear reactions has three stages;

compiling a list of frightening situations or stimuli with an indication of their significance or hierarchy;

learning a method muscle relaxation in order to form the skill to create a physical condition.

gradual presentation of a frightening stimulus or situation in combination with the use of a muscle relaxation method.

23. Model of mental pathology in the cognitive approach

In the early 1960s, clinicians Albert Ellis and Aaron Beck suggested that cognitive processes underlie behavior, thinking, and emotions and that we can best understand abnormal functioning by studying cognitive ability- an approach known as the cognitive model. Ellis and Beck argued that clinicians should ask questions about what assumptions (premises) and attitudes imprint a person's perception, what thoughts flash through his mind and what conclusions they lead to.

cognitive explanations.

Abnormal functioning may result from several types of cognitive problems. For example, people may hold assumptions and attitudes about themselves and their world that are disturbing and inaccurate.

Cognitive theorists also point to illogical thought processes as a possible cause of abnormal functioning. For example, Beck found that some people over and over again think in an illogical way and draw conclusions that harm them.

Cognitive methods of therapy.

According to cognitive therapists, people with psychological disorders can get rid of their problems by learning new, more functional ways of thinking. Since different forms of anomaly can be associated with different types of cognitive dysfunction, cognitive therapists have developed a number of techniques. For example, Beck developed an approach, simply called cognitive therapy, that is widely used in cases of depression.

Cognitive therapy is a therapeutic approach developed by Aaron Beck that helps people recognize and change their faulty thought processes.

Therapists help patients recognize the negative thoughts, biased interpretations, and logical fallacies that abound in their thinking and that, according to Beck, cause them to become depressed. Therapists also encourage patients to challenge their dysfunctional thoughts.

Evaluation of the cognitive model.

Advantages: 1) its focus is on the most unique of human processes - human thinking. 2) Cognitive theories are also the object of numerous studies. Scientists have found that many people with psychological disorders do have flawed assumptions, thoughts, or thought processes. 3) the success of cognitive therapies. They have proven to be very effective in treating depression, panic disorder, and sexual dysfunctions.

Disadvantages: 1) although cognitive processes are clearly involved in many forms of pathology, their specific role has yet to be determined. 2) although cognitive therapies certainly help many people, they cannot help everyone. 3) the cognitive model is characterized by a certain narrowness.

It was developed in the 60s of the XX century by the American psychiatrist Aaron Beck. The main idea of ​​this form of therapeutic treatment is the belief that a person's thoughts, emotions and behavior mutually influence each other, creating patterns of behavior that are not always appropriate.

A person, under the influence of emotions, fixes certain forms of behavior in certain situations. Sometimes copies the behavior of others. He reacts to various phenomena and situations in the way he is used to, often without realizing that he is harming others or himself.

Therapy is needed when behavior or beliefs are not objective and can create problems for normal life. Cognitive-behavioral therapy allows you to detect this distorted perception of reality and replace it with the right one.

Cognitive behavioral therapy - for whom

Cognitive behavioral therapy is best suited for the treatment of disorders based on anxiety and depression. This therapy is very effective and is therefore most often used in the treatment of patients with phobias, fears, epilepsy, neuroses, depression, bulimia, compulsive disorders, schizophrenia and post-traumatic stress disorder.

Psychotherapy is the most commonly used treatment for psychiatric disorders. It can be the only form of work on the patient's psyche or supplement drug treatment. A feature of all types of psychotherapy is the personal contact of the doctor with the patient. In psychotherapy, they use different approaches, in particular, psychoanalysis, humanistic-existential therapy, cognitive-behavioral approach. Cognitive Behavioral Therapy considered one of the most clinically studied forms of therapy. Its effectiveness has been proven by many studies, so doctors often use this proven method of psychotherapy.

Cognitive Behavioral Therapy Course

Cognitive Behavioral Therapy focuses on current issues, the here and now. In treatment, most often, they do not turn to the past, although there are exceptional situations when this is unavoidable.

Duration of therapy about twenty sessions, once or twice a week. The session itself does not usually last more than one hour.

One of the most important elements successful treatment is the cooperation of the psychotherapist with the patient.

Thanks to cognitive behavioral therapy, it is possible to identify factors and situations that have an effect. distorted perception. In this process, highlight:

• stimulus, that is, the specific situation that causes the patient's action
• specific way of thinking patient in a particular situation
• feelings and physical sensations, which are a consequence of specific thinking
• behavior (actions), which, in fact, represent the patient.

AT cognitive behavioral therapy the doctor tries to find a connection between the thoughts, emotions and actions of the patient. He must analyze difficult situations and find thoughts that lead to a misinterpretation of reality. At the same time, it is necessary to inspire the patient with the irrationality of his reactions and give hope for the possibility of changing the perception of the world.

Cognitive Behavioral Therapy - Methods

This form of therapy uses many behavioral and cognitive techniques. One of them is the so-called Socratic dialogue. The name comes from a form of communication: the therapist asks questions to the patient. This is done in such a way that the patient himself discovers the source of his beliefs and tendencies in behavior.

The role of the doctor is to ask a question, listen to the patient and pay attention to the contradictions that arise in his statements, but in such a way that the patient himself comes to new conclusions and solutions. In Socratic dialogue, the therapist uses many useful methods, such as paradox, probing, etc. These elements, through appropriate application, effectively influence the change in the patient's thinking.

In addition to the Socratic dialogue, the doctor may use other methods of influence, for example, shifting attention or scattering. During therapy, the doctor also teaches methods of dealing with stress. All this in order to form in the patient the habit of adequate response to the conditions of a stressful situation.

The result of cognitive behavioral therapy is not only a change in behavior, but also the patient's awareness of the consequences of introducing these changes. All this in order for him to form new habits and reactions.

The patient must be able to respond appropriately to negative thoughts if there are any. The success of therapy lies in the development in the person of appropriate responses to these stimuli, which previously led to misinterpretation.

Benefits of Cognitive Behavioral Therapy

In favor of cognitive-behavioral therapy speaks, first of all, its high efficiency, has been repeatedly confirmed by clinical studies.

The advantage of this type of treatment is the development of self-awareness of the patient, who, after therapy, achieves self-control over his behavior.

This potential remains in the patient also after the end of therapy, and allows him to prevent the recurrence of his disorder.

An additional benefit of therapy is the improvement in the patient's quality of life. He receives an incentive to activity and higher self-esteem.

Introduction……………………………………………………………………………………………………………3

1. Theoretical base……………………………………………………………………………………….3

2. Methods of behavioral therapy ..………………………………………………………………..4

2.1 Stimulus control techniques………………………………………………………………………….4

2.2.Consequence control techniques………………………………………………………………..9

2.3. Learning from models……………………….……………………………………………………….11
Introduction

Behavioral psychotherapy is one of the main directions in foreign psychotherapy. In the domestic literature, her methods were usually used under the name of conditioned reflex psychotherapy. It was formed between 1950 and 1960 and is associated with the names of A. Lazarus, J. Wolpe, G. Eysenck, S. Rahman, B. Skinner.

Theoretical base

Theory of reflexes I.P. Pavlova.
Experiments on conditioned reflexes have shown that the formation of a conditioned reaction is subject to a number of requirements:

1) adjacency - coincidence in time of indifferent and unconditioned stimuli;

2) repetition, but with certain conditions formation after the first combination is possible.

3) the higher the intensity of the need, the easier the conditioned reflex is formed.

4) a neutral stimulus must be strong enough to stand out from the general background of stimuli;

5) the extinction of the conditioned reflex after the termination of its reinforcement occurs gradually and not completely;

6) the most resistant to extinction are conditioned reflexes formed with a variable interval and a variable ratio.

7) it is important to take into account the law of generalization and differentiation of the stimulus.

At the second stage of the development of behavioral psychotherapy, theories of instrumental or operant conditioning acted as theoretical foundations.

The formation of a conditioned reaction takes place through trial and error, as a result of the choice (selection) of the desired standard of behavior and its subsequent consolidation on the basis of the law of effect.

It is formulated as follows: behavior is fixed (controlled) by its results and consequences.

Instrumental reflexes are controlled by their outcome, and in classical conditioned reflexes responses are controlled by the presentation of the preceding stimulus.

The main ways to change behavior in therapy:

1. Impact on the consequences (results) of behavior and

2. Management of stimulus presentation.

3. Correcting inappropriate behavior and teaching adequate behavior.

Man is a product of the environment and at the same time its creator. Behavior is formed in the process of learning and learning. Problems arise as a result of flaws in learning. The consultant is an active party: he plays the role of a teacher, a coach, trying to teach the client more effective behavior. The client must actively test new ways of behaving. Instead of a personal relationship between the consultant and the client, a working relationship is established to carry out the training procedures.

the main objective– formation and improvement of skills. These techniques also improve self-control.

Behavioral psychotherapy is designed to reduce human suffering and limit a person's ability to act.

The concept of mental disorders is based on the notion that “disturbed” or “abnormal” behavior can be explained and changed along the same lines as “normal” behavior.

In the behavioral approach, everything is based on “functional analysis”, the essence of which is to describe complaints in the form of psychological problems (problem analysis) and find out those basic conditions, the change of which will lead to a change in the problem and find out those basic conditions, the change of which will lead to a change in the problem . For the analysis, a multilevel analysis is used (micro- and macro-perspectives).

Basic points of behavioral therapy:

1. Using the achievements of fundamental empirical psychological research, especially the psychology of learning and social psychology;

2. Orientation to behavior as a mental variable that can be formed or suppressed as a result of learning;

3. Predominant (but not exclusive) concentration on present rather than past determinants of behavior;

4. Emphasis on empirical testing of theoretical knowledge and practical methods;

5. Significant predominance of methods based on training.

Behavior Therapy Methods

Stimulus control techniques

A group of techniques by which the patient is given a strategy for coping with problem situations.

A classic example of stimulus control is the so-called. methods of confrontation in the behavior of avoidance, due to fear.

In the presence of anticipated fear, when the patient is not able to endure certain situations, the task of the psychotherapist is to encourage the client to confront the frightening situation, then extinction and overcoming of fear can occur. According to cognitive learning theory, the patient's problem in the behavioral repertoire remains so stable precisely because, due to complete avoidance, the person does not experience safe behavior, and therefore no extinction occurs.

If a person seeks to get out of a situation that he considers dangerous as quickly as possible, then avoidance is additionally negatively reinforced.

In the process of confrontation, the patient must gain concrete experience in the cognitive, behavioral and physiological plane and experience that confrontation with a subjectively disturbing situation does not entail the expected "catastrophe"; having passed the "plateau" in excitement, fear is removed in several planes, which also leads to an increase in faith in one's own ability to overcome.

Techniques can be varied: systematic desensitization, exposures, flooding techniques, implosion techniques, and paradoxical interventions. The emphasis in them may be on control or self-control, but in all there is a confrontation of the individual with a situation that causes fear. Such a situation is realized with a gradually increasing intensity of fear and in the representation, or really (in vivo), or without growth and really (exposure), or to carry out massively - either in the representation (implosion), or really (flood). Self-control implies compliance with the rule, that therapy is carried out step by step by the patient. When a patient takes step-by-step self-monitoring, it makes a huge difference both ethically and in terms of sheer effectiveness and cost/benefit ratio.

Systematic desensitization

Method systematic desensitization suggests that pathogenic responses are maladaptive responses to an external situation.

After being bitten by a dog, the child extends his reaction to all kinds of situations and to all dogs. Afraid of dogs on TV, in a picture, in a dream ...

Task: to make the child insensitive, resistant to a dangerous object.

Elimination mechanism: the mechanism of mutual exclusion of emotions, or the principle of reciprocity of emotions. If a person experiences joy, then he is closed to fear; if relaxed, then also not subject to reactions of fear.

Therefore, if you “immerse” in a state of relaxation or joy, and then show stressful stimuli, then there will be no fear reactions.

Methodology: in a person in a state of deep relaxation, ideas about situations leading to the emergence of fear are evoked. Then, by deepening relaxation, the patient relieves the emerging anxiety.

There are 3 stages in the procedure:

1. Mastering the technique of muscle relaxation,

2. Drawing up a hierarchy of situations that cause fear,

3. Actually desensitization (connection of representations with relaxation)

Relaxation is a universal resource. The technique of progressive muscle relaxation according to E. Jacobson is used.

He suggested that the relaxation of the muscles entails a decrease in the neuro- muscle tension. He also noticed that a different type of response corresponds to the tension of a certain muscle group. Depression - tension of the respiratory muscles; fear - muscles of articulation and phonation. Differentiated relaxation of muscle groups can selectively influence negative emotions.

In the course of progressive muscle relaxation, with the help of concentration of attention, the ability to catch muscle tension and a feeling of muscle relaxation is first formed, then the skill of mastering voluntary relaxation of tense muscle groups is developed.

All muscles of the body are divided into sixteen groups. The sequence of exercises is as follows: from the muscles upper limbs(from the hand to the shoulder, starting with the dominant hand) to the muscles of the face (forehead, eyes, mouth), neck, chest and abdomen and further to the muscles lower extremities(from hip to foot, starting with the dominant leg).

Exercises begin with a short-term, 5-7-second, tension of the first muscle group, which then completely relax within 30-45 seconds; attention is focused on the feeling of relaxation in that area of ​​the body. The exercise in one muscle group is repeated until the patient feels complete muscle relaxation; Only then do they move on to the next group.

To successfully master the technique, the patient must perform the exercise independently during the day twice, spending 15-20 minutes on each exercise. As the skill in relaxation is acquired, muscle groups become larger, the strength of tension in the muscles decreases, and gradually attention is increasingly focused on the memory.

With the help of a psychotherapist, the client builds a hierarchy of stimuli that provoke, first of all, anxiety, and then reproduce psychotrauma as a whole. Such a hierarchy should include 15-20 objects. It is also important to organize incentives correctly. Then he is presented with these stimuli, starting with the most harmless. Stressfulness of stimuli should increase gradually. After he copes with one stimulus, the next one is presented.

When presenting stimuli, two methods can be used: either desensitization in the imagination, or graduated exposure (in vivo desensitization).

Desensitization in the imagination is that the client, being in a state of relaxation, imagines scenes that cause him anxiety, imagines the situation for 5-7 seconds, then eliminates anxiety by increasing relaxation. This period lasts up to 20 seconds. The performance is repeated several times. If the alarm does not occur, then move on to the next more difficult situation on the list.

On the final stage the client, after daily analysis of local muscle tensions arising from anxiety, fear and excitement, independently achieves muscle relaxation and thus overcomes emotional stress.

Stepwise, graded exposure (or in vivo desensitization) suggests that the patient must be exposed to anxiety-producing stimuli (starting with the weakest) in real life accompanied by a therapist who encourages them to increase their anxiety. Faith in and contact with the therapist is a counter-conditioning factor.

This option is preferred by most psychotherapists, since it is the collision with stressors in real life that is always ultimate goal treatment, and this method is more effective.

Other types of desensitization:

1. Contact desensitization - in addition to bodily contact with an object, modeling is also added - performing actions on the list by another person without fear.

2. Emotive imagination - identification with a favorite hero and the hero's encounter with situations that cause fear. This option can be used in real life as well.

3. Game desensitization.

4. Drawing desensitization.

Many of the methods used in behavioral therapy require the use of an exposure technique in which the patient is exposed to fear-inducing stimuli or conditioning stimuli.

This is done in order to create conditions for the extinction (as the situation becomes habitual) of the conditioned reflex emotional reaction to this set of incentives. It's believed that this technique can also serve as a means of refuting the patient's expectations or beliefs about certain situations and their consequences.

There are several varieties of treatments based on the use of exposure techniques; they differ depending on the way the stimuli are presented (the patient can be exposed to them in imagination or in vivo) and the intensity of the impact (whether a gradual transition to stronger stimuli is carried out during treatment or the patient is immediately confronted with the most powerful of them). In some cases, for example, when adapting to traumatic memories during the treatment of post-traumatic stress disorder, already due to the specific nature of the disorder, only exposure in the imagination is applicable.

Similarly, the patient's irrational thoughts are challenged by exposing him to situations that show that these ideas are false or unrealistic.

Dive, flood

If the approach used in desensitization could be compared to how a person is taught to swim first in a shallow place, gradually moving to a depth, then when “immersing” (using the same analogy), on the contrary, he is immediately thrown into whirlpool.

When using this method, the patient is placed in the most difficult situation for him, related to the top of the hierarchy of stimuli (this may be, for example, a visit to a crowded store or a bus ride at rush hour), and he must be exposed to it until until the anxiety disappears spontaneously ("acquiring a habit"). The technique emphasizes the value of a quick collision, experiencing a strong emotion of fear. The sharper the collision with the situation, the longer it lasts, the more intense experience, all the better.

The essence of the technique is that a long-term exposure to a traumatic object leads to transcendental inhibition, which is accompanied by a loss of psychological sensitivity to the impact of the object. The patient must make sure that there are no possible negative consequences. The patient, together with the therapist, finds himself in a traumatic situation until the fear begins to decrease. Covert avoidance mechanisms should be excluded. It is explained to the patient that covert avoidance-reducing the subjective level of fear reinforces this avoidance further. The procedure takes an hour and a half. The number of sessions is from 3 to 10.

Flooding and desensitization difference parameters:

1) fast or slow confrontation (collision) with a stimulus that causes fear;

2) the emergence of intense or weak fear;

3) the duration or short duration of the encounter with the stimulus.

While many are not easy to convince to go for it, immersion is faster and more effective method than desensitization.

implosion

Implosion is a flood technique in the form of a story, imagination.

The therapist writes a story that reflects the patient's main fears. The goal is to create maximum fear.

The task of the psychotherapist is to maintain a sufficiently high level of fear, not to let it decrease for 40-45 minutes.

After several sessions, you can move on to the flood.

Paradoxical Intention

The patient is asked to stop fighting the symptom and deliberately bring it on voluntarily or even try to increase it.

Those. it is necessary to radically change the attitude towards the symptom, the disease. Instead of passive behavior - the transition to an active offensive on your own fear.

The evoked anger technique uses anger as a reciprocal inhibitor of fear and is based on the assumption that anger and fear cannot coexist at the same time.

In the process of in vivo desensitization, at the moment of the appearance of fear, they are asked to imagine that at that moment something was insulted or something happened that caused intense anger.

Stimulus control techniques are based on the premise that for some stimuli the relationship between stimulus and response is quite rigid.

Events that precede behavior can be grouped as follows:

1) discriminant stimuli, in the past associated with a certain reinforcement,

2) facilitating stimuli that promote the flow of certain behavior (new clothes can help develop communication),

3) conditions that increase the strength of reinforcement (deprivation period).

It is necessary to teach the patient to identify discriminant and facilitating stimuli in a real situation, to identify conditions that increase the strength of reinforcement of unwanted behavior, and then remove stimuli that cause such behavior from the environment.

Teaching the patient to reinforce the stimuli associated with the "correct" desired behavior. They teach the ability to correctly manipulate the period of deprivation, without bringing it to the level of loss of control.

Consequence Control Techniques

They imply managing problem behavior through consequences.

Techniques related to the control of consequences are called operant methods or situational control strategies.

The consequences of some problematic and target behavior are organized in such a way that, as a result, the frequency of the target behavior increases (for example, through positive reinforcement), and the problem behavior (through operant extinction) becomes less frequent.

These techniques solve the following tasks:

1. Formation of a new stereotype of behavior,

2. Strengthening the already existing desirable stereotype of behavior,

3. Weakening of undesirable stereotype of behavior,

4. Maintaining the desired stereotype of behavior in natural conditions.

The solution to the problem of reducing undesirable stereotypes of behavior is achieved using several techniques:

1) punishments,

2) extinction;

3) saturation,

4) deprivation of all positive reinforcements,

5) evaluation of the answer.

Punishment is the technique of applying a negative (abusive) stimulus immediately following a response that is being suppressed.

As a negative stimulus, a painful, subjectively unpleasant stimulus is most often used, and then this technique actually turns into an aversive one.

It can also be social incentives (ridicule, condemnation), but they are purely individual.

Methods of direct punishment have an extremely limited value: punishing and aversive methods lead to a number of ethical problems, so their use is legitimate only in extreme cases (alcoholism, pedophilia)

Punishment

Efficiency conditions:

1. Negative stimulus is applied immediately, immediately after the response.

2. Scheme of application of the aversive stimulus: at the first stage, suppression by means of continuous application of the aversive stimulus; further - a non-permanent extinction scheme.

3. The presence in the repertoire of the patient's behavior of alternative responses is an important condition for the implementation of the technique (but for this, the behavior must be purposeful, i.e. the goal retains its significance and the patient is actively looking for it).

extinction

Extinction is the principle of the disappearance of reactions that are not positively reinforced.

The rate of extinction depends on how the undesirable stereotype was reinforced in real life. This method requires considerable time, with an initial period of increase in frequency and strength first.

Depriving all positive reinforcements is one option for extinction. The most effective is isolation.

Response evaluation could more accurately be called a penalty technique. It is used only with positive reinforcement. In addition, positive reinforcement is reduced for unwanted behavior.

Satiation is a behavior that is positively reinforced but continues. long time, tends to deplete itself, and positive reinforcement loses its power. Usually not used separately. The art of the psychotherapist in skillful use various combinations methods.

Trial Therapy

Trial therapy is an aversive mechanism in which it is prescribed to perform a task that causes even more discomfort than the symptom itself (for insomnia, spend the whole night reading a book standing up).

Uncontrolled pathological skill is deautomatized by its arbitrary daily implementation.

With enuresis, the task is given to wake up if the bed is wet and do calligraphy.

It is necessary to implement a number of steps of the method:

1. Clear identification of the symptom. (Find only excessive anxiety when doing 40 squats, not normal).

2. Strengthening motivation for healing.

3. The choice of the type of test (it should be harsh, but beneficial).

Model Learning

These techniques occupy an intermediate position between classical behavioral and cognitive ones.

They play a crucial role in role play or in training in self-confidence and social competence.

By observing the behavior of other people (and the consequences of this behavior), they learn this behavior or change the pattern of their own behavior in the direction of the behavior of the model.

The observer can quite quickly learn to imitate and adopt even very difficult ways behavior and actions.

During role play behavior is reinforced (behavior training) and transferred to real situations.

Model learning most economically overcomes social phobias and shapes appropriate interactional behavior.

Forming ways of social behavior in aggressive and inhibited children helps in the formation of target behavior, and in many cases where verbal methods are difficult (good for treating children).

It is important to remember that in the eyes of patients, the psychotherapist has the function of a model in all respects.

Behavioral psychotherapy is based on the "aspirin metaphor":

it is enough to give aspirin so that the head does not hurt, i.e. no need to look for the cause of the headache - you need to find the means to eliminate it.

Behavioral Psychotherapy

Behavioral Psychotherapy is based on techniques for changing pathogenic reactions (fear, anger, stuttering, enuresis, etc.). It is important to remember that behavioral therapy is based on the "aspirin metaphor": if a person has a headache, then it is enough to give aspirin, which will relieve headache. This means that you do not need to look for the cause of the headache - you need to find the means to eliminate it. It is obvious that the lack of aspirin is not the cause of the headache, but, nevertheless, its use is often sufficient. Let us describe specific methods and the sanogenic mechanisms inherent in them.

At the core method of systematic desensitization lies the idea that pathogenic reactions (fear, anxiety, anger, panic disorder etc.) are a non-adaptive response to some external situation. Suppose a child is bitten by a dog. He was afraid of her. In the future, this adaptive reaction, which makes the child be careful with dogs, generalizes and extends to all kinds of situations and all kinds of dogs. The child begins to be afraid of a dog on TV, a dog in a picture, a dog in a dream, a small dog that has never bitten anyone and sits in the arms of its owner. As a result of such generalization, the adaptive response becomes maladaptive. A task this method consists in the desensitization of a dangerous object - the child must become insensitive, resistant to stressful objects, in this case - to dogs. To become insensitive means not to react with a fear response.

The mechanism for eliminating non-adaptive reactions is the mechanism of mutual exclusion of emotions, or the principle of reciprocity of emotions. If a person experiences joy, then he is closed to fear; if a person is relaxed, then he is also not subject to reactions of fear. Therefore, if a person is "immersed" in a state of relaxation or joy, and then shown to him stressful stimuli (in this example - different kinds dogs), then the person will not have fear reactions. It is clear that stimuli with a low stress load should be presented initially. The stressfulness of the stimuli should increase gradually (from a drawing of a small dog with a pink bow named Pupsik to a large black dog named Rex). The client must progressively desensitize stimuli, starting from weak ones and gradually moving to stronger ones. Therefore, it is necessary to build a hierarchy of traumatic stimuli. The step size in this hierarchy should be small. For example, if a woman has an aversion to male genital organs, then the hierarchy can be started with a photograph of a naked 3-year-old child. If immediately after that you present a photograph of a naked teenager 14-15 years old, then the step will be very large. The client in this case will not be able to desensitize the male genitals upon presentation of the second photograph. Therefore, the hierarchy of stressful stimuli should include 15–20 objects.

Equally important is the proper organization of incentives. For example, a child has a fear of exams. You can build a hierarchy of teachers from less “terrible” to more “terrible” and consistently desensitize them, or you can build a hierarchy of psycho-traumatic stimuli according to the principle of temporary proximity to exams: woke up, washed, did exercises, had breakfast, packed a portfolio, dressed, went to school, came to school, went to the classroom door, entered the classroom, took a ticket. The first organization of stimuli is useful in the case when the child is afraid of the teacher, and the second is in the case when the child is afraid of the actual situation of exams, while treating teachers well and not being afraid of them.

If a person is afraid of heights, then one should find out in what specific situations in his life he encounters heights. For example, these can be situations on a balcony, on a chair while screwing in a light bulb, in the mountains, on a cable car, etc. The client’s task is to remember as many situations in his life as possible in which he has encountered fear of heights, and arrange them in order of increasing fear. One of our patients experienced first respiratory discomfort, and then increasingly intensifying sensations of suffocation when leaving the house. Moreover, the further the client moved away from home, the more this discomfort was expressed. Beyond a certain line (for her it was a bakery) she could only walk with someone else and with a constant feeling of suffocation. The hierarchy of stressful stimuli in this case was based on the principle of distance from home.

Relaxation is a universal resource that allows you to cope with many problems. If a person is relaxed, then it is much easier for him to cope with many situations, for example, approaching a dog, moving away from home, going out on a balcony, taking an exam, getting closer to a sexual partner, etc. In order to bring a person into a state of relaxation, used progressive muscle relaxation technique according to E. Jacobson.

The technique is based on a well-known physiological pattern, which consists in the fact that emotional stress is accompanied by tension of the striated muscles, and calming is accompanied by their relaxation. Jacobson suggested that the relaxation of the muscles entails a decrease in neuromuscular tension.

In addition, while registering objective signs of emotions, Jacobson noticed that a different type of emotional response corresponds to the tension of a certain muscle group. So, depression accompanied by tension of the respiratory muscles, fear - by a spasm of the muscles of articulation and phonation, etc. Accordingly, removing, through differentiated relaxation, the tension of a particular muscle group, you can selectively influence negative emotions.

Jacobson believed that each area of ​​the brain is connected to the peripheral neuromuscular apparatus, forming a cerebro-neuromuscular circle. Arbitrary relaxation allows you to influence not only the peripheral, but also central part this circle.

Progressive muscle relaxation begins with a conversation, during which the therapist explains to the client the mechanisms therapeutic effect muscle relaxation, emphasizing that the main goal of the method is to achieve voluntary relaxation of the striated muscles at rest. Conventionally, there are three stages of mastering the technique of progressive muscle relaxation.

The first stage (preparatory). The client lies on his back, bends his arms in elbow joints and sharply strains the muscles of the hands, thereby causing a clear sensation of muscle tension. The arms then relax and fall freely. This is repeated several times. At the same time, attention is fixed on the sensation of muscle tension and relaxation.

The next exercise is contraction and relaxation of the biceps. The contraction and tension of the muscles should first be as strong as possible, and then more and more weak (and vice versa). With this exercise, it is necessary to fix attention on the feeling of the weakest muscle tension and their complete relaxation. After that, the client exercises the ability to strain and relax the muscles of the flexors and extensors of the trunk, neck, shoulder girdle, and finally, the muscles of the face, eyes, tongue, larynx and muscles involved in facial expressions and speech.

The second stage (properly differentiated relaxation). The client in the sitting position learns to tense and relax the muscles that are not involved in maintaining the body in an upright position; further - to relax when writing, reading, speech, the muscles that are not involved in these acts.

Third stage (final). The client, through self-observation, is invited to establish which muscle groups are tensed in him with various negative emotions (fear, anxiety, excitement, embarrassment) or painful conditions (with pain in the heart area, increased blood pressure etc.). Then, through the relaxation of local muscle groups, one can learn to prevent or stop negative emotions or painful manifestations.

Progressive muscle relaxation exercises are usually mastered in a group of 8-12 people under the guidance of an experienced psychotherapist. Group classes are held 2-3 times a week. In addition, clients conduct self-study sessions on their own 1-2 times a day. Each session lasts from 30 minutes (individual) to 60 minutes (group). The entire course of study takes from 3 to 6 months.

After the technique of progressive muscle relaxation has been mastered and a new reaction has appeared in the behavioral repertoire of the client - the reaction of differentiated relaxation, desensitization can begin. Desensitization is of two types: imaginal (in the imagination, in vitro) and real (in vivo).

In imaginal desensitization, the therapist positions himself next to the seated (lying) client. The first step - the client plunges into a state of relaxation.

The second step - the therapist asks the client to imagine the first object from the hierarchy of psychogenic stimuli (a small dog, the genitals of a 3-year-old child, going outside, etc.). The patient's task is to go through the imaginary situation without tension and fear.

The third step is that, as soon as any signs of fear or tension arise, the patient is asked to open their eyes, relax again, and re-enter the same situation. The transition to the next stressful object is carried out if and only if the desensitization of the first object of the hierarchy is completed. In some cases, the patient is asked to inform the therapist about the occurrence of anxiety and tension. index finger right or left hand.

In this way, all objects of the identified hierarchy are sequentially desensitized. When, in imagination, the patient is able to pass through all objects, i.e. leave the house, walk to the bakery and go further, climb into a chair, calmly look at the male genitalia, desensitization is considered complete. The session lasts no more than 40-45 minutes. As a rule, 10-20 sessions are required to desensitize fear.

Relaxation is not the only resource that allows you to cope with a stressful object. Moreover, in some cases it is contraindicated. For example, one 15-year-old girl, a fencer, developed a syndrome after two defeats in a row. anxious expectation loss. In her imagination, she constantly replayed frightening situations of defeat. In such a case, relaxation, plunging into a losing situation, might make the patient calmer, but would not help her win. In this case, the resource experience can be confidence.

concept resource experience or state used in Neuro Linguistic Programming (NLP) and is not specific to behavioral or any other psychotherapy. At the same time, behavioral psychotherapy is associated with the possibilities of using a positive (resource) state to change the response to a traumatic stimulus. In the above case, confidence can be found in the athlete's past - in her victories. These victories were accompanied by a certain psycho-emotional upsurge, confidence and special sensations in the body. The most important thing in this case is to help the client to restore these forgotten feelings and experiences, on the one hand, and to be able to quickly access them, on the other. The client was asked to tell in detail about her most important victory recent years. Initially, she talked about this in a very detached way: she talked about external facts, but did not report anything about her experiences of joy and the corresponding sensations in the body. This means that positive experience and positive experiences are dissociated and there is no direct access to them. In the process of remembering her own victory, the client was asked to recall as many details as possible related to external events: how she was dressed, how she was congratulated on her victory, what was the reaction of the coach, etc. After that, it became possible to “go into” internal experiences and sensations in the body - a straight back, elastic, springy legs, light shoulders, easy, free breathing, etc. feelings and bodily sensations. After the memories of defeat situations ceased to traumatize her and did not find a response in the body (tension, anxiety, feelings of powerlessness, difficulty in breathing, etc.), it could be stated that past traumas ceased to have a negative impact on the present and future.

The next step in psychotherapy was the desensitization of the traumatic image of the future defeat, which was formed under the influence of past defeats. Due to the fact that these past defeats no longer support a negative image of the future (expectation of defeat), its desensitization became possible. The client was asked to present her future opponent (and she knew her and had experience of fighting with her), the strategy and tactics of her performance. The client imagined all of this in a positive state of confidence.

In some cases, it is quite difficult to teach a client relaxation, since he can refuse any independent work needed to master this technique. Therefore, we use a modified desensitization technique: the patient sits in a chair or lies on a couch, and the therapist gives him a “massage” of the collar zone. The purpose of such a massage is to relax the client, to ensure that he rests his head in the hands of the therapist. Once this happens, the therapist asks the client to talk about the traumatic situation. At the slightest sign of tension, the client is distracted by asking him extraneous questions that lead away from the traumatic memories. The client must re-relax, and then again asked to talk about the trauma (failed sexual experience, fears about the upcoming sexual contact, fear of entering the subway, etc.). The task of the therapist is to help the client talk about the trauma without leaving the relaxed state. If the client is able to repeatedly talk about the trauma while remaining calm, then we can assume that the traumatic situation is desensitized.

In children, the emotion of joy is used as a positive experience. For example, in order to desensitize the darkness in case of fear of it (to be in a dark room, to go through a dark corridor, etc.), the child is offered to play hide and seek with friends. The first step in psychotherapy is for the children to play blind man's blind in a lighted room. As soon as a child suffering from the fear of the dark becomes interested in the game, feels joy and emotional uplift, the illumination of the room begins to gradually decrease until the child plays in the dark, rejoicing and completely unaware that it is dark around. This is an option game desensitization. The well-known child psychotherapist A. I. Zakharov (Zakharov, p. 216) describes play desensitization in a child who was afraid of loud sounds from neighboring apartments. The first stage is the actualization of the situation of fear. The child was left alone in a closed room, and his father knocked on the door with a toy hammer, while frightening his son with cries of “U-u!”, “A-a!”. On the one hand, the child was frightened, but on the other hand, he understood that his father was playing with him. The child was filled with mixed feelings of joy and wariness. Then the father opened the door, ran into the room and began to “hit” his son on the ass with a hammer. The child ran away, again experiencing both joy and fear. At the second stage there was an exchange of roles. The father was in the room, and the child "frightened" him, knocking on the door with a hammer and making menacing sounds. Then the child ran into the room and pursued the father, who, in turn, was defiantly frightened and tried to dodge the blows of the toy hammer. At this stage, the child identified himself with the force - knocking and at the same time saw that its effect on the father only causes a smile and is an option. fun game. At the third stage, a new form of reaction to knocking was consolidated. The child, as at the first stage, was in the room, and his father "scared" him, but now it only caused laughter and a smile.

There is also pictorial desensitization fears, which, according to A.I. Zakharov, is effective for children aged 6–9 years. The child is asked to draw a psycho-traumatic object that causes fear - a dog, a fire, a subway turnstile, etc. Initially, the child draws a big fire, a huge black dog, large black turnstiles, but the child himself is not in the picture. Desensitization consists in reducing the size of the fire or dog, changing their ominous color, so that the child can draw himself on the edge of the sheet. By manipulating the size of the traumatic object, its color (one thing is a big black dog, another is a white dog with a blue bow), the distance in the picture between the child and the psychotraumatic object, the size of the child himself in the picture, the presence of additional figures in the picture (for example, mother), names of objects (the dog Rex is always more afraid than the dog Pupsik), etc., the psychotherapist helps the child to cope with the psycho-traumatic object, to master it (in normal situation we always control fire, but a child who survived a fire feels uncontrollability, the fatality of fire) and thereby desensitizes.

There are various modifications of the desensitization technique. For example, NLP offers overlay and “swipe” techniques (described below), a technique for viewing a traumatic situation from end to beginning (when the usual obsessive memory cycle is disrupted), etc. Desensitization as a direction of psychotherapeutic work is present in one form or another in many techniques and approaches of psychotherapy. In some cases, such desensitization becomes independent technique, for example, F. Shapiro's eye movement desensitization technique.

One of the most common methods of behavioral psychotherapy is flood technique. The essence of the technique is that a long-term exposure to a traumatic object leads to extreme inhibition, which is accompanied by a loss of psychological sensitivity to the impact of the object. The patient, together with the therapist, finds himself in a traumatic situation that causes fear (for example, on a bridge, on a mountain, in a closed room, etc.). The patient is in this situation of "flooding" with fear until the fear begins to subside. This usually takes an hour and a half. The patient should not fall asleep, think about other things, etc. He should be completely immersed in fear. The number of flooding sessions can vary from 3 to 10. In some cases, this technique is also used in a group form.

There is also a flooding technique in the form of a story, which is called implosion. The therapist writes a story that reflects the patient's main fears. For example, one client after breast removal had a fear of returning oncological disease and, consequently, the fear of death. The woman had intrusive thoughts about her symptoms of cancer. This individual mythology reflected her naive knowledge of the disease and its manifestations. This individual mythology of cancer should be used in the story, as it is this that causes fear. During the story, the patient may experience dying, cry, she may shake. In this case, it is important to take into account the adaptive capabilities of the patient. If the trauma presented in the story exceeds the patient's ability to cope, then he may develop quite deep mental disorders that require urgent therapeutic measures. It is for this reason that flood and implosion techniques are rarely used in Russian psychotherapy.

Technique aversions is another option for behavioral psychotherapy. The essence of the technique is to punish a non-adaptive reaction or "bad" behavior. For example, in case of pedophilia, a man is offered to watch a video in which objects of attraction are shown. In this case, electrodes are applied to the patient's penis. When an erection occurs, caused by watching a video, the patient receives a weak electric shock. With several repetitions, the “object of attraction-erection” connection is broken. Demonstration of the object of attraction begins to cause fear and expectation of punishment.

In the treatment of enuresis, the child is given electrodes of a special apparatus so that when urinating during a night's sleep, the circuit closes and the child receives an electrical discharge. When using such a device for several nights, enuresis disappears. As noted in the literature, the efficiency of the technique can reach up to 70%. This technique is also used in the treatment of alcoholism. A group of alcoholics are allowed to drink vodka with an emetic added to it. The combination of vodka and emetic is supposed to lead to aversion to alcohol. However, this technique has not proven its effectiveness and is currently practically not used. However, there is a domestic option for the treatment of alcoholism using the aversion technique. This is the well-known method of A. R. Dovzhenko, which is a variant of emotional stress psychotherapy, when the patient is intimidated with all sorts of terrible consequences if alcohol abuse continues, and against this background, a sober lifestyle program is offered. With the help of the aversion technique, stuttering, sexual perversions, etc. are also treated.

Technique for the formation of communication skills considered one of the most effective. Many human problems are determined not by some deep, hidden reasons but lack of communication skills. In the technique of teaching structural psychotherapy by A.P. Goldstein, it is assumed that the development of specific communication skills in a particular area (family, professional, etc.) allows solving many problems. The technique consists of several stages. At the first stage, a group of people who are interested in solving a communicative problem (for example, people who have problems in marital relations) gathers. Group members fill out a special questionnaire, on the basis of which specific communication deficits are identified. These deficits are seen as the absence of certain communication skills, such as the ability to give compliments, the ability to say “no”, the ability to express love, etc. Each skill is broken down into components, thus forming a certain structure.

In the second stage, group members are encouraged to identify the benefits they will receive if they master the relevant skills. This is the motivation stage. As group members become aware of the benefits they will receive, their learning becomes more targeted. At the third stage, the group members are shown a model of a successful skill using a video recording or a specially trained person (for example, an actor) who fully possesses this skill. At the fourth stage, one of the trainees tries to repeat the demonstrated skill with any of the group members. Each approach should take no more than 1 minute, because otherwise the rest of the group members start to get bored, and it is necessary to work positive attitude. The next step is the feedback step. Feedback should have the following qualities:

1) be specific: you can’t say “it was good, I liked it”, but you should say, for example, “you had Nice smile”, “You had a great tone of voice”, “when you said “no”, you did not leave, but, on the contrary, touched your partner and showed your disposition”, etc .;

2) be positive. You should celebrate the positive, and not focus on what was bad or wrong.

Feedback is given in the following order: group members-co-actors-trainer. At the sixth stage, trainees receive homework. They must demonstrate the relevant skill in real conditions and write a report about it. If the trainees have passed all the stages and consolidated the skill in real behavior, then the skill is considered mastered. No more than 4-5 skills are mastered in a group. Technique is good in that it does not focus on obscure and incomprehensible changes, but is aimed at mastering specific skills. The effectiveness of the technique is measured not by what the trainees liked or disliked, but by the specific result. Unfortunately, in the current practice of psychological groups, effectiveness is often determined not real result, but those pleasant experiences that are largely caused not by the depth of change, but by security and surrogate satisfaction of infantile needs (found support, praise - received positive feelings that may not be focused on real changes).