behavioral methods. Behavioral Psychotherapy

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;

training in any method of 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.

The manual “Children and Adolescents Behavior Correction” describes in detail the organizational and methodological issues of behavioral psychotherapy, including legal and ethical standards, principles of remuneration for work, features of therapy in medical and educational institutions, as well as counseling centers. The main methods used in behavior modification are described, as well as general techniques for the formation of intellectual and social skills and overcoming stress, which are necessary when working with any category of problems.

The situation with the psychotherapy of children and adolescents in Germany has completely changed due to the adoption of the law on psychotherapists. After the entry into force of this law on January 1, 1999, behavioral therapy for children and adolescents was singled out as an independent branch of psychotherapy. Behavioral therapy can be carried out by psychologists and educators who have completed a course special training. The services of psychotherapists officially admitted to work in associations of health insurance funds are paid according to the established tariffs.

The passage of the law contributed to the revival of behavioral therapy for children and adolescents; many specialists began to receive remuneration for their work; demand for basic education in this area of ​​psychotherapy is growing; parents and educators are less skeptical than before about the conduct of psychotherapeutic treatment by methods of behavioral therapy, and its methods of influence, or interventions , are positively evaluated in the media (eg, interventions to reduce the severity of aggressive and delinquent behavior, hyperkinetic disorders in children, childhood anxiety).

However, there is still uncertainty about what actually constitutes the essence of child and adolescent behavioral therapy; whether therapy should be behaviorally oriented; whether simple discussion of everyday problems is behavioral therapy; how much therapy should go into the analysis of the details of everyday life. A brief excursion into the history of behavioral therapy in children and adolescence can give the first answers to the questions posed.

Historical digression

The tradition of behavioral therapy for children and adolescents has almost 80 years of history. Its formation and development is closely intertwined with adult therapy, many therapeutic methods were first tested on children and adolescents before being applied to adults. Over time, child and adolescent therapy has increasingly receded into the background.

There are four main stages in the development of behavioral therapy.

On the first stage (1920s) therapy was mainly oriented towards theoretical teachings (classical conditioning, operant conditioning, behaviorism). For example, Watson and Rayner published a report in 1920 about an eleven-month-old infant who developed a fear of a white rat after its repeated appearance was accompanied by a loud, frightening noise. Then his fear generalized, i.e. began to be transferred to other objects covered with fur. Thus, it was proved that fear can appear according to the model of classical conditioning.

A few years later, Jones (1924) published the results of a therapy that used the mechanisms of classical conditioning to eliminate fear in a child who was afraid of rabbits. Children's fear was overcome with the help of desensitization method. Subsequently, reports began to appear about methods of therapy based on classical conditioning and treatment mechanisms derived from it (partial confrontation with stimuli that cause fear, desensitization).

On the second stage therapy was carried out under the influence of the paradigm operant conditioning(in particular, B. Skinner). Therapeutic techniques were very close to everyday situations, and therapists tried to change the problem behavior of children with the help of methods developed in the 1930s and 1940s. laws of learning. At first, a very scrupulous study was carried out of the difficulties in the behavior of the child (in particular, detailed analysis the behavior of the reference faces of the child, observations were made of behavior in everyday life, observations of the relationship between mother and child, and the mother and child were behind glass.

In accordance with this approach, diagnosis was aimed not so much at a differentiated classification of symptoms (for example, oppositional defiant disorder F91.3), but rather at establishing certain functional disorders. Therefore, therapy focused, in particular, on modifying the contingency of adults' behavior in a domestic environment or on changing other situational conditions (for example, when children do homework).

It was very characteristic of the second stage of the development of therapy that the success of therapeutic measures was directly checked against the plan for conducting therapy. The content of such a plan was, in particular, that at the first stage it reflected the frequency of manifestations of, say, oppositional-aggressive behavior at the observation stage without therapeutic interventions, and then at the second stage (the intervention stage) therapeutic principles were used (for example, ignoring aggressive behavior of the student on the part of the teacher, as well as the systematic strengthening of normative behavior). At the third stage, these principles were removed, and at the fourth stage they were introduced again (the so-called therapeutic plans). If the frequency of manifestations of aggressive-oppositional behavior of the child in such conditions did indeed systematically decrease, then this indicated the correctness of the therapeutic approach and the interventions used.

In this way, therapeutic measures were focused mainly on everyday behavior and changing living conditions (for example, modifying the behavior of adults). This approach gave a large number of well-controlled outcomes in individual cases (for example, with manifestations of autism in early childhood, stereotypy, aggressiveness). Accordingly, therapy sought primarily to change the functional conditions and relationships in everyday life. Its purpose was, for example, to change the educational behavior of parents, to consciously create situations (in particular, when a student does homework, including the behavior of parents), train parents and teachers as mediators, use remuneration in schools and at home (in the form of tokens), the systematic formation of the desired behavior.

On the third stage (in the late 1970s) there was a turn towards cognitive therapy, which led to a stronger tilt of therapy towards the personality and its structuring behavior. Researchers such as Kanfer, Mahoney, Meichenbaum, Ellis, Beck no longer proceeded from the direct conditionality of difficulties and problems in the child's behavior, as suggested by B. Skinner and adherents of the operant paradigm. On the contrary, they believed that behavior is regulated by cognitive structures (eg, self-prescriptions, situational perceptions, beliefs, irrational beliefs, attitudes). But thinking, according to this therapeutic model, is ultimately nothing but internalized speaking(self-instruction). This led to the conclusion that the task of therapy is the learning of self-prescriptions, a covert appeal to oneself and, as a result, internalized speaking, i.e. thinking.

With this approach, the child had to learn better and better to control his behavior in everyday life. This therapeutic approach is closely related to the laws of learning, but it expands the methodological spectrum by introducing a method of changing self-prescriptions, modifying the perception of everyday situations, and developing social and cognitive skills. Therapy, therefore, could be built in the form of a series of modeling exercises 1 (training), thanks to which the child learned to develop appropriate self-prescriptions and transfer them to everyday situations with the help of adults. (1 This refers to exercises that model one or another desired behavior. — Note. scientific. ed.)

During this period, many therapeutic guidelines appeared (in particular, to reduce impulsivity, reduce aggressive behavior, improve self-assertion, increase social competence), which, on the one hand, offer characteristic exercises with children, and, on the other hand, structure the interaction of the child with reference adults ( parents, teachers). The development and use of such therapy manuals is also being stimulated more and more. wide application classification systems for diseases and disorders (International Classification mental disorders ICD-9, World Health Organization classification), as more exact definition homogeneous groups of violations.

During the 1980s formed fourth stage child and adolescent therapy, which has increasingly moved away from its focus on behavior. Obviously, this happened under the influence of adult therapy that was dominant at that time. The goal of therapy was not so much the modification of specifically observed behavior (the success of therapy was measured by changing the problematic behavior for the better in everyday situations), but cognition change(in particular, the formation of appropriate situational perceptions in aggressive children, setting cognitive tasks of average complexity for children who do not want to learn, teaching impulsive children self-prescriptions, etc.).

The advantage of this new orientation was that, moving away from everyday life, therapy began to gravitate toward the organizational forms of the "medical therapeutic model." The possibility of conducting therapy in the premises provided for it and in the framework of conversations with parents and the children themselves has significantly increased. At the same time, not so much specific behavioral deviations in everyday situations were subjected to therapy, but attitudes towards certain moments of everyday life. Along with many advantages (which include, in particular, a noticeable expansion of the methodological spectrum), this approach had a drawback: relatively high requirements were imposed on the client (for example, in the field of speech proficiency, prudence, motivation), which are beyond the power of small, lagging behind in their development to children and adolescents who do not want to undergo psychotherapy. As a result, therapy began to be mainly applied to older children, who were dominated by difficulties and problems of an introverted nature (fears, depression, self-esteem problems), and younger children who were lagging behind in development and negatively disposed to psychotherapy (in particular, aggressive ones) turned out to be on periphery of attention of therapists. In addition, the child and his parents had to apply their knowledge of therapy in everyday practice, which is not always possible.

This similar medical approach is also stimulated by the use of classification systems of differential diagnosis (International Classification of Mental Disorders ICD-9 or ICD-10). For example, in order to recognize "hyperkinetic disorder" (F90.1), observations of reference adults (parents and teachers), observations in the therapist's office, and a differential diagnostic examination, which can also be carried out in the therapist's office, are quite sufficient. Home visits by a therapist, observation of the mother-child relationship, or method of direct observation of the child's behavior in kindergarten are not required (and are not paid from the health insurance fund).

This short digression shows that we have at our disposal a wide and well-tested arsenal of methodological tools, which, however, in modern behavioral therapeutic practice not fully used. Moreover, some well-established and readily available methods and techniques (eg, training of cotherapists, systematic influence on reinforcing contingencies, bringing therapy closer to everyday conditions, establishing a diagnosis in everyday life) are clearly not used enough in our time.

Age groups and main types of disorders

Behavioral therapy deals with children and adolescents of a wide age range. It addresses four clearly differentiated age groups in which there are age types violations.

infants and early age(from 0 to 3 years). This group is dominated by characteristic disorders and disorders (feeding and eating disorders, communication disorders, developmental delays, and various developmental disorders) that have so far received little attention from behavioral therapists. Hence the lack of interest in the great rarity of therapeutic interventions (although behavioral-therapeutic concepts are successful). Modern therapy concerns mainly pediatric, ergotherapeutic, physiotherapeutic, medical-pedagogical and socio-pedagogical activities.

Preschool age (from 3 to 6 years old). Developmental disorders dominate (in particular, speech, movement disorders), but behavioral disorders also appear (in particular, aggressiveness, anxiety). This group receives a lot of attention from behavioral therapists, however, interventions are not carried out within the framework of a behavioral therapy paradigm, but rather in the context of curative-pedagogical, family-therapeutic or occupational therapy and pediatric interventions.

School age (from 6 to 14 years old). In principle, in children of this age, you can find any violations. However, they concentrate in the area of ​​school-relevant behaviors (eg, learning difficulties and underachievement, described developmental disorders). This age category in most cases enjoys close attention of behavioral therapists.

Teenagers (from 14 to 18 years old). The problems of adaptation and self-esteem dominate (in particular, anorexia, bulimia, depression, learning difficulties, academic failure, drug addiction, aggressiveness, delinquent behavior). This group can be considered as the most well-off in terms of behavioral therapy, since the treatment of adolescents is largely organized similarly to the treatment of adults. However, the adolescent group with extraverted disorders (antisocial behavior, delinquency) is relatively little covered by behavioral therapy.

Thus, in the field of behavioral and therapeutic support, one can detect the presence of obvious “white spots”: first of all, we are talking about insufficient coverage of children of the youngest age group and children (adolescents) with expansive forms of behavioral disorders. It can be assumed that the reasons for this deficit lie in the insufficient speech development of young children, their inability to understand the significance of therapy for them, the lack of the necessary interdisciplinary interaction and the direct influence on the structuring of the daily life of clients (for example, the optimization of family relationships, the impact on the educational behavior of significant adults). Older children who are more accessible to therapists and have a fairly developed language (for example, anxious children or children with depressive symptoms) are more likely to use the appropriate services of therapists. This is because therapy is mostly removed from the situations of everyday life and is carried out in the process. direct contact between therapist and client.

Behavioral Disorders and Therapy Perspectives

Disorders in children and adolescents depend on context, i.e. from certain situations, the action of certain stimuli, personal contacts and forms of interaction. Quite often there are rather transient deviations in behavior that disappear with the normalization of material and social conditions (Esser, Schmidt, Blanz, Fätkenheuer, Fritz, Koppe, Laucht, Rensch, Rothenberger, 1992). This conclusion is important from a diagnostic and therapeutic point of view. For diagnosis, it follows that the causes that cause and maintain problematic behavior in the spirit of a behaviorist analysis of environmental conditions should be identified as close as possible to everyday conditions; for therapy - intervention measures should also be aimed at the environment, i.e. are aimed at changing situations and optimizing the interaction of the patient with other people, as well as modifying the behavior of reference persons.

Disorders in childhood and adolescence are more often classified on the basis of statistical data (in particular, based on factor and cluster analyses). Such studies typically identify several factors that describe the type of disorder (eg, social behavior disorder, anxiety, indecision and timidity, immaturity syndromes, psychotic disorders, and autism). It is also partially possible to classify disorders in terms of their "localization" (for example, extravertive and introvertive disorders, as well as mixed syndromes).

Descriptive classification systems, on the contrary, give a limited number of categories of violation, differentiated by their content. The International Classification of Mental Disorders (International Classification of Diseases - ICD-10; WHO, 1994) distinguishes, for example, the following categories of diseases, which, as a rule, apply to both adults and children:

• F1: mental and behavioral disorders due to the use of psychoactive substances (particularly alcohol, F10; sedatives and hypnotics, F13);
• F2: schizophrenia, schizotypal and delusional disorders (in particular, hebephrenic schizophrenia, F20.1; schizotypal disorder, F21);
• F3: affective disorders mood (eg, depressive episode, F32; recurrent depressive disorder, F33);
• F4: neurotic, stress-related, and somatoform disorders (e.g., phobias, F40; obsessive-compulsive disorder, F42; response to severe stress and adjustment disorders, F43);
• F5: behavioral syndromes associated with physiological disturbances and physical factors (eg eating disorders, F50.0; psychological and behavioral factors associated with disorders classified elsewhere, F54);
• F6: disorders of adult personality and behavior (eg, pathological gambling, F63.0; gender identity disorders, F64);
• F7: mental retardation (eg, mild mental retardation, F70; severe mental retardation, F72);
• F8: Violations psychological development(e.g. specific developmental speech disorder, F80; expressive speech disorder, F80.1; specific reading disorder, F81.0; specific numeracy disorder, F81.2; childhood autism, F84.0);
• F9: behavioral and emotional disorders with onset usually in childhood and adolescence (eg, hyperkinetic disorders, F90; oppositional defiant disorder, F91.3; childhood separation anxiety disorder, F93.0; social anxiety disorder childhood, F93.2; childhood-onset social functioning disorder, F94; reactive attachment disorder of childhood, F94.1; tics, F95; inorganic enuresis, F98.0; eating disorders in infancy, F98.2; stereotypical movement disorders, F98.4).

All these violations differ from each other very significantly, therefore, the main tasks of treatment are set differently.

The goal of therapy for some of the previously mentioned disorders is to reduce the frequency of their manifestation (eg, phobias, obsessions, enuresis, aggressiveness). Therapy aggressiveness aimed, in particular, at reducing its intensity and teaching the client to follow the rules more. An essential feature of behavioral therapy is, therefore, to systematically introduce reinforcing conditions into the child's daily life. This can be achieved through targeted stimulation of the child's behavior by parents and teachers, for which a “token” reward system and other everyday incentives are used (for example, joint interesting pastime in the family circle, increased attention to the child). If necessary, behavioral training is carried out in order to increase the control of impulsivity, empathy towards the child, who learns the appropriate social skills and their application in everyday situations through the receipt of reinforcing stimuli. Such operant and environmentally shaping activities, including the behavior of the adults most important to the child, are indicated primarily for the treatment of behavioral disorders in children. younger age.

Other forms of impairment (for example, the developmental disorders described) are characterized by the fact that the child does not master important behavioral skills, and the goal of therapy is thus the systematic formation of complex behavioral complexes. This is especially true developmental disorders(F8) organic disorders (F0) and mental retardation (F7). These violations are characterized by a breakdown in the mechanism of information processing. Children are not able to build enough connection between stimulus and response because, for example, their central nervous system is damaged. nervous system or stimuli are not accurately perceived, accumulated in memory and translated into specific actions (for example, a child suffering from reading and writing disorders fails to link together images of oral and writing). In the process of therapy for such children, it is primarily about the systematic development of activity skills using the methods of behavior formation (shaping), the preparation of new forms of behavior (prompting, fading), as well as the systematic stimulation of behavioral progress. This technique is similar to neuropsychological functional training, which is also practiced in work with adult clients. At the same time, one should regularly and systematically increase the difficulty of training exercises and constantly encourage the child's activity in achieving more significant results. For minors and less developed children these activities should be carried out mainly in cooperation with parents, teachers and educators (training of co-therapists).

In case of phobias and post-traumatic disorders on the contrary, measures of graded presentation of stimuli of varying intensity to the client against the background of stabilizing measures are shown. At the same time, the client is exposed step by step to the situation that causes anxiety and fear in him, in order to experience and process the traumatic experience. Important role in this process, techniques are also played that increase self-esteem and help the child (adolescent) develop the ability to successfully solve the next developmental task (for example, graduating from school, forming friendships with peers, etc.).

Somatic diseases(eg migraine, chronic ailments) and psychotic disorders(eg, schizophrenia) involve the use of psychotherapy accompanying treatment medical means. This support consists, as a rule, in carrying out psycho-educational activities addressed to the child and his family (for example, the communication of information, the development of treatment-friendly forms of behavior). In addition, it aims to develop clients' competence in dealing with their illness over a long period of time (for example, cognitive training for schizophrenic patients, relaxation training for asthma patients, coping with migraine stress).

Diagnostic measures

Therapy of children and adolescents is usually preceded by a broad and thorough diagnostics. This is important, if only because in most cases, children and adolescents did not undergo a preliminary examination (for example, by a pediatrician or in a clinic). Accordingly, the diagnosis should provide a broad basis for orientation of the therapist, establishing the severity of the disorder, and, if possible, the cause of its occurrence. This includes, above all, detailed developmental history the child, his or her previous impairments, including a broad survey of current complaints about difficulties and behavioral problems. In the process of making a diagnosis, hypotheses are developed about the possible causes of the disorder (in particular, organic damage that distorts behavior, educational influences on the part of parents, developmental disorders and partial delays in working capacity). These hypotheses are purposefully verified in the process of diagnosing.

In the course of deepening the diagnosis, it is recommended definition of cognitive and intellectual prerequisites in a child (adolescent) (identifying the level of general mental development, conducting multidimensional intellectual testing, assessing its partial performance). It is also necessary to observe how the child interacts with the immediate environment (interactions along the mother-child line, during classes, at home). Often there is a need to identify somatic diseases child.

In the course of the diagnostic measures is in the foreground behaviorally-analytical survey specific difficulties of problematic behavior and its conditioning; the differential diagnostic assignment of a behavioral problem within a particular system of classification of diseases for therapy plays a rather secondary role.

Intervention principles

Regardless of the type of violation and applicable intervention methods(classical conditioning, operant conditioning, situational therapy, resource-oriented therapy, competence orientation, cognitive therapy) there are a number of generally valid principles of therapy for children and adolescents.

Involvement of significant persons in the process of therapy. Treatment of young children, children with developmental delays is impossible without the participation of parents, teachers and educators. At the same time, the task should be to change the conditions of the child's social context as purposefully as possible (behavior of parents and other reference persons, recommendations to family members, assistance to the development of the child in preschool). Environmental modification can, for example, take place within training of cotherapists during which the mother of a child with a developmental delay learns how to support her child's speech development on a daily basis (in particular in the form of regular exercises, stimulation of speech progress, recording developmental progress).

The therapist can influence the daily routine established in the family or the behavior of caregivers (for example, when putting the child to bed, the manner in which certain tasks are set for the child). Problematic behavior can be corrected by direct contingent incentives.

In all these cases, the therapist needs to know how specific interactions take place in “local conditions”, actively involve parents in the process of therapeutic activities (in particular, by informing parents about the conditions that cause problematic behavior of the child, providing reference persons with precise instructions, by training referent persons as part of the desired intervention). In addition, there is a need for regular exchange of information and observations between the therapist and reference persons during interventions. It is also important to define operational criteria for measuring problem behavior and therapy outcomes(e.g. number of words spoken, number of ticks in the afternoon).

Orientation of therapy to specific changes behavior. This approach generally corresponds to the model of behavioral therapy, which defines disorders in the form of specific concepts (“excessive activity”, “insufficient activity”, “lack of competence”, “self-regulation disorders”, “dysfunctional processing of stimuli”), considers it possible to learn behavior depending from the context and, therefore, evaluates the success of therapy by how the behavior modification proceeds. By pursuing specific behavioral goals (for example, the child must first work 10, then 15 and 25 minutes in a lesson without interference), behavioral therapy has several advantages: more targeted interaction with specific teachers is established, this interaction is more amenable to regulation, and behavioral indicators - control, individual difficulties and problems are directly and directly affected. Collaboration with a particular teacher, on the contrary, would be difficult if the goals of therapy were unclear (vague mutual expectations, indefinite forms interventions, insufficient criteria for the success of therapy). True, targeting specific behavioral goals can lead to general acceptance problems on the part of the child (for example, "the child must always be considered in its entirety").

Carrying out therapy in vivo (parental home, Kindergarten , school, boarding school). Therapeutic measures achieve their goal when they manage to directly and, if possible, directly influence the change in the conditions of the child's daily environment that cause and support the child's problem behavior. If, for example, a four-year-old child suffers from urinary incontinence during the day, then exact time when he is taken to the toilet, who does it, how it happens, how “success” in the toilet is encouraged, and what to do if the diaper is wet again.

Similar programs, carried out in the home directly by reference adults, are also used in cases of procrastination, provocative behavior, developmental delays, anxiety, and so on. At the same time, the cooperation of a psychologist with a kindergarten and a school is of great importance. In this area, one can often observe professional rivalry (pedagogy and psychology) and competition between different psychotherapeutic areas (psychoanalysis versus behavioral therapy). It is very useful to focus the interaction of therapists and cotherapists on specific, perhaps even preliminary goals of behavioral therapy, to agree on specific activities and criteria for evaluating therapy.

Development orientation. Problems in the behavior of children and adolescents are closely related to the course of development and its age-related tasks. Individual disorders (for example, enuresis, speech development disorders) are directly defined as age-related, i.e. considered problematic only from a certain age. Other violations appear only when moving from one ecological environment to another, when new requirements are presented to the child (for example, when entering a kindergarten). This fact affects the design of therapy, since it is always aimed at optimizing the conditions for the development of the child, for example: increasing the educational competence of parents, reducing traumatic stressors in the family, improving family communication, and, finally, increasing the competence of the children themselves. In this regard, behavioral therapy is focused on developmental resources and competence. It is about not only reducing the severity of problem behavior, but generally clearing the way for a more successful development of the child.

Interdisciplinary collaboration of a psychotherapist with doctors, caregivers, teachers, physiotherapists, speech therapists. This cooperation begins already at the stage of diagnosis, especially in cases of developmental and well-being disorders.

In working with this category of violations, it is necessary to find out medical aspects, in particular the causes of sleep disturbances, speech development, motor, nutritional or excretory disorders (for example, taking an encephalogram, hearing tests, neurological examination, study of the functions of digestion and Bladder). Interdisciplinary cooperation is also required in the implementation of therapy, which takes place in part with the participation of teachers and educators, and also requires the coordination of various treatment methods (for example, physiotherapy, speech therapy, drug treatment). As a rule, the task of coordination falls on the responsible behavioral therapist, who must monitor the achievement of specific behavioral goals and strive for a clear differentiation of therapeutic interventions.

All these principles boil down to the fact that therapy should be carried out as concretely and empirically as possible. The day-to-day therapeutic impact prevails over the discussion of the disorder.

Efficiency

The finding that behavioral therapy for children and adolescents produces positive results is not new. However, more and more information has recently emerged about different efficiency individual methods. M. Döpfner (1999) published a review article, which concludes that the therapy of both external and internal disorders gives both medium and high results (from 0.76 to 0.91).

This is also confirmed by the data of meta-analyses conducted, in particular, by J.R. Weisz (1995), who summarized 150 studies from 1967 to 1993. Children aged 2 to 18 years underwent therapy, with an average efficiency of 0.71.

According to A.E. Kazdin and J.R. Weisz, the following methods of behavioral therapy for children and adolescents have proven themselves well in terms of effectiveness:

• cognitive behavioral therapy for introversion disorders (fears, phobias);
• teaching (through training) skills to cope with depression in children and adolescents (eg, detecting depressive patterns, learning social skills or practicing progressive muscle relaxation, encouraging positive experiences that have a beneficial effect on the client's mood);
• training in cognitive problem solving in the presence of externalized disorders (for example, in aggressive and oppositional children);
• training of parents suffering from the same type of disorder;
• therapy of antisocial forms of behavior by involving the social environment (family, school, peers, neighbors, etc.);
• family-oriented interventions in the presence of difficulties in raising young children;
• intensive family-oriented behavioral therapy for autism;
• special events in special occasions, for example, in the preparation of invasive interventions through cognitive behavior modification.

Many new studies support the conclusion that behavioral therapy interventions in children and adolescents are highly effective; this applies to both contingent management and cognitive-behavioral techniques (eg, self-prescription or cognitive behavior modification).

With regard to expansive disorders (including attention deficit, hyperactive disorders), clearly structured programs aimed at implementing in everyday living conditions and optimizing the control of the behavior of a problem child by parents, teachers, etc. seem to be especially effective. (Pelham, Wheeler, Chronis, 1998). These programs often outperform CBT methods (Saile, 1996).

It is much more difficult to measure the effectiveness of interventions for developmental disorders.

On the one hand, there are many individual studies on the treatment of speech disorders, spelling problems, autism symptoms, etc., which have given very nice results. Moreover, it is possible to achieve lasting results in overcoming difficulties and violations of partial working capacity at school: children who have undergone appropriate training have become much less likely to encounter problems at school.

On the other hand, it is necessary to constantly repeat courses of therapy for disorders such as autism and similar developmental disorders in order to avoid long-term relapses.

It is with autistics that problems arise, depending on whether measures to promote their development were included in educational programs. S.R. Forness et al. have shown that training in specific developmental functions (including memory development strategies) has a very effective effect on clients, but only when the training programs are well structured and problem oriented and when therapeutic interventions are continually adapted to the developmental progress children are making. .

(Laut G.AT., Marriage.B., Linderkamp F. Correction of the behavior of children and adolescents: A practical guide. I. Strategy and methods / transl. with him. V.T. Altukhova; scientific ed. Russian text by A.B. Kholmogorov. - M .: Ed. Center "Academy", 2005. - S. 8-19.)

Behavioral Psychotherapy - this is perhaps one of the youngest methods of psychotherapy, but along with this, it is one of the methods prevailing today in modern psychotherapeutic practice. The behavioral direction in psychotherapy emerged as a separate method in the middle of the 20th century. This approach in psychotherapy is based on various behavioral theories, the concepts of classical and operant conditioning, and the principles of learning. The key task of behavioral psychotherapy is to eliminate unwanted behaviors and develop useful behaviors. The most effective use of behavioral techniques in the treatment of various phobias, behavioral disorders and addictions. In other words, such states in which one can detect some individual manifestation as a so-called "target" for further therapeutic effects.

Cognitive Behavioral Psychotherapy

Today, cognitive-behavioral direction in psychotherapy is known as one of the most effective methods assistance with depressive states and preventing suicidal attempts by subjects.

Cognitive-behavioral psychotherapy and its techniques are a technique that is relevant in our time, which is based on a significant role in the origin of complexes and various psychological problems. cognitive processes. The individual's thinking performs the main function of cognition. American psychiatrist A. T. Beck is considered the creator of the cognitive-behavioral method of psychotherapy. It was A. Beck who introduced such fundamental conceptual concepts and models of cognitive psychotherapy as the description of anxiety and , the scale of hopelessness and the scale used to measure suicidal ideas. This approach is based on the principle of transforming the individual's behavior to reveal existing thoughts and identify those thoughts that are the source of problems.

Cognitive Behavioral Therapy and its techniques are used to eliminate negative thoughts, create new thought patterns and problem analysis methods, and reinforce new statements. These techniques include:

- detection of desirable and unnecessary thoughts with further determination of the factors of their occurrence;

— design of new templates;

- using imagination to visualize the alignment of new patterns with desired behavioral responses and emotional well-being;

- application of new beliefs in real life and situations where main goal will accept them as a habitual way of thinking.

Therefore, today cognitive-behavioral psychotherapy is considered a priority area of ​​modern psychotherapeutic practice. Teaching the patient the skills to control their own thinking, behavior and emotions is her most important task.

The main emphasis of this approach of psychotherapy is on the fact that absolutely all psychological problems of a person come from the direction of his thinking. It follows from this that it is absolutely not circumstances that are the main barrier on the way of an individual to a happy and harmonious life, but the personality itself develops an attitude towards what is happening with its own mind, forming in itself far from the most good qualities like panic. A subject who is not able to adequately assess the people around him, the significance of events and phenomena, endowing them with qualities that are not characteristic of them, will always be overcome by various psychological problems, and his behavior will be determined by the formed attitude towards people, things, circumstances, etc. For example, in the professional sphere, if the boss of the subordinate enjoys unshakable authority, then any of his points of view will immediately be accepted by the subordinate as the only correct one, even if that the mind will understand the paradoxical nature of such a view.

In family relationships, the influence of thoughts on the individual has more pronounced features than in the professional sphere. Quite often, most subjects find themselves in situations in which they fear some important event, and then, after its occurrence, begin to understand the absurdity of their own fears. This happens due to the contrived nature of the problem. When faced with any situation for the first time, an individual evaluates it, which is later imprinted in memory as a template, and later, when a similar situation is reproduced, the behavioral reactions of the individual will be determined by the existing template. That is why individuals, for example, survivors of a fire, move several meters away from the source of fire.

Cognitive-behavioral psychotherapy and its techniques are based on the discovery and subsequent transformation of the internal "deep" conflicts of the personality, which are available for its awareness.

Today, cognitive-behavioral psychotherapy is considered practically the only area of ​​psychotherapy that has confirmed its high performance in clinical experiments and has a fundamental scientific basis. Now even an association of cognitive-behavioral psychotherapy has been created, the purpose of which is to develop a system for the prevention (primary and secondary) of psycho-emotional and mental disorders.

Methods of behavioral psychotherapy

The behavioral direction in psychotherapy concentrates on the transformation of behavior. Key difference this method psychotherapy from others is, first of all, that therapy is any form of learning new patterns of behavior, the absence of which is responsible for the occurrence of problems psychological nature. Quite often, training involves the elimination of erroneous behaviors or their modification.

One of the methods of this psychotherapeutic approach is aversive therapy, which involves the use of unpleasant stimuli for the individual in order to reduce the likelihood of painful or even dangerous behavior. More often, aversive psychotherapy is used in cases where other methods have not shown results and with severe symptoms, for example, with dangerous addictions such as alcoholism and drug addiction, uncontrolled outbreaks, self-destructive behavior, etc.

Today, aversive therapy is considered as an extreme undesirable measure, which should be used with caution, while not forgetting to take into account numerous contraindications.

This type of therapy is not used as a separate method. It is used only in conjunction with other techniques aimed at developing substitution behavior. The elimination of undesirable behavior is accompanied by the formation of desirable. Also, aversive therapy is not recommended for individuals suffering from severe fears and for patients who are obviously inclined to run away from problems or unpleasant situations.

Aversive stimuli should be used only with the consent of the patient, who has been informed of the essence of the proposed therapy. The client must have full control over the duration and intensity of the stimulus.

Another method of behavioral therapy is the token system. Its meaning lies in the client receiving symbolic things, for example, tokens for any useful action. The individual can subsequently exchange the received tokens for pleasant and important objects or things for him. This method is quite popular in prisons.

In behavioral therapy, one should also highlight such a method as a mental “stop”, i.e. trying to stop thinking about what can cause negative emotions, discomfort. This method has become widespread in modern therapy. It consists in pronouncing the word "stop" by the patient to himself at the time of the occurrence of unpleasant thoughts or painful memories. This method is used to eliminate any painful thoughts and inhibiting feelings, negative expectations in various fears and depressive states, or positive ones in various addictions. Also this technique it can also be used in case of loss of relatives or other loved ones, career failure, etc. It is easily combined with other techniques, does not require the use of complex equipment and is quite time-consuming.

In addition to these methods, others are also used, for example, learning on models, phased reinforcement and self-reinforcement, learning reinforcement techniques, and self-instruction, systematic desensitization, hidden and targeted reinforcement, self-assertion training, penalty system, conditioned reflex therapy.

Cognitive-behavioral psychotherapy teaching the basic mechanisms, principles, techniques and techniques is today considered one of the priority areas modern psychotherapy, as it is applied with equal success in all possible areas of human activity, for example, in enterprises when working with personnel, in psychological counseling and clinical practice in pedagogy and other fields.

Behavioral Therapy Techniques

one of the pretty known methods in behavioral therapy, the technique of flooding is considered. Its essence lies in the fact that prolonged exposure to a traumatic situation leads to intense inhibition, accompanied by a loss of psychological susceptibility to the influence of the situation. The client, together with the psychotherapist, finds himself in a traumatic situation, causing fear. The individual is in a “flood” of fear until the period when the fear itself begins to subside, which usually takes from one hour to one and a half. In the process of "flooding" the individual should not fall asleep or think about outsiders. He should completely plunge into fear. Sessions of "flood" can be carried out from three to 10 times. Sometimes this technique can be used in group psychotherapeutic practice. Thus, the “flooding” technique is the repeated reproduction of disturbing scenarios in order to reduce their “probable anxiety”.

The technique of "flood" has its own variations. So, for example, it can be carried out in the form of a story. In this case, the therapist composes a story that reflects the patient's dominant fears. However, this technique should be carried out with extreme caution, because in the case when the trauma described in the story exceeds the client's ability to cope with it, he may develop quite deep violations psyches requiring immediate medical measures. Therefore, implosion and flood techniques are used extremely rarely in domestic psychotherapy.

There are also several other popular techniques in behavioral therapy. Among them, systematic desensitization is widely used, which consists in teaching deep relaxation of muscles in a state of stress, a token system, which is the use of incentives as a reward for "correct" actions, "exposure", in which the therapist stimulates the patient to enter a situation that gives rise to fear in him. .

Based on the foregoing, it should be concluded that the main task of the psychotherapist in the behavioral approach to psychotherapeutic practice is to influence the client's attitudes, the course of his thoughts and the regulation of behavior in order to improve his well-being.

Today, in modern psychotherapy, the further development and modification of cognitive-behavioral techniques, their enrichment with techniques from other areas is considered quite important. For this purpose, an association of cognitive-behavioral psychotherapy was created, the main tasks of which are the development of this method, the unification of specialists, the provision of psychological assistance, the creation of various training courses and psycho-correction programs.

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 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 it can be changed by changing the way the person thinks and emotionally relates 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 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 - classic 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).

They are used to identify special exercise- the patient should 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 spend leisure time, etc. Learning 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 of responding 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, and his own (and not imposed from the outside) work on mistakes. CBT can take many 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 social adaptation former drug addict;
• reduces the risk of breakdowns in the future.

Studies have shown that CBT shows the best results in treatment. Methods of cognitive-behavioral therapy are also widely used in getting rid of cocaine addiction.