2. The main directions of modern psychotherapy.

Plan.

1. The main directions of modern psychotherapy: psychodynamic, cognitive-behavioral, existential-humanistic.
2. Comparative characteristics of the goals, objectives, concepts of health and pathology, the position of the psychotherapist and methods of work.

1.

With all the variety of psychotherapeutic approaches, there are three main directions in psychotherapy (psychodynamic, behavioral, humanistic). In the framework of the psychodynamic approach, unconscious mental processes are considered as the main determinants of personal development and behavior, neurosis (personality disorders) are understood as a consequence of the conflict between the unconscious and consciousness, psychotherapy will be aimed at achieving awareness of the conflict and its own unconscious. The psychoanalytic method itself is subordinate to this task. Awareness is achieved through the analysis of free associations. Symbolic manifestations of the unconscious, resistance and transference. The procedure is designed to promote the manifestation of the unconscious. This determines the content of the process of psychotherapy, the degree of its structure, the strategy and tactics of the psychotherapist, his role and position. Activity level, intensity and frequency of sessions.

Representatives of the behavioral approach focus their attention on behavior as the only psychological reality available to direct observation. The purpose of psychological intervention is maladaptive behaviors on adaptive (reference, normative, correct). Methodically, learning is carried out on the basis of basic theories or models of learning that exist in behaviorism (classical and operant conditioning, learning by model, social learning).

The humanistic direction proceeds from the recognition of the human person and considers the need for self-realization and self-actualization as the basic need. Neurosis is a consequence of the impossibility of self-actualization: insufficient self-understanding, incomplete self-acceptance, insufficient integrity of the “I”. The goal of psychological intervention will be to create conditions in which a person can experience a new emotional experience that promotes awareness and acceptance of oneself, integration. The need to create such conditions determines the specific characteristics of the psychotherapist's behavior, its role, position, orientation and style.

1. 
   
   1. The main directions, or approaches, in psychotherapy are three: psychodynamic, phenomenological (existential-humanistic), behavioral (cognitive-behavioral).
      
      Psychodynamic approach
      
      Freud's idea that all symptoms are a reaction to a conflict caused by the frustration of infantile sexual impulses. There are many varieties of psychodynamic theories of personality and the treatment of emotional disorders.
      
      They pay more attention to current problems and how one can use “the power of the ego” to solve them. In these therapies, clients are helped to realize not the “Oedipus Complex”, but how the deepest feelings of anxiety, uncertainty and inferiority lead to emotional disturbances and problems in relations with others.
      
      This includes primarily the individual psychology of Alfred Adler, who emphasized the role of innate social motives in the formation of personality. Adler suggested that each person is born in a helpless, dependent state that creates a feeling of inferiority. This negative feeling, combined with the natural desire to become a "fledged" member of society, is an incentive for personal development. Adler explained this process as a desire for excellence, which meant the desire for self-fulfillment, and not just the desire to be better than others. If feelings of inferiority are very strong, then they lead to compensation, even overcompensation of inferiority, to an “inferiority complex”. Neurosis develops if a person fails to overcome an inferiority complex; neurosis allows the patient to maintain self-esteem, attributing his weakness due to illness.
      
      Another type of psychoanalysis is egopsychology (Anna Freud, Hartman, Klein). Egopsychologists considered “ego” not only as a mediator in the conflicts between the “id”, “superego” and the environment, but as a creative, adaptive force. Ego is responsible for language development, perception, attention, planning, learning, and other psychological functions.
      
      Neo-Freudian theorists, such as Karen Horney, Erich Fromm, Harry Sulliven, followed Adler’s path, concentrating on how the social environment is involved in the formation of personality. They believed that the most important for the formation of personality is the satisfaction of social needs - needs for security, security, recognition (acceptance). When these needs are not met, people experience severe discomfort and seek to solve the problem, using other people, getting from them what they need. The strategies used to do this - the desire for superiority over others, or, conversely, excessive dependence on others - form the personality. Sullivan attached so much importance to interpersonal relationships that he defined the personality as an "individual's interpersonal behavior pattern."
      
      In the modern psychodynamic approach, theorists of object relations, such as Melanie Klein, Otto Kernberg, Heinz Kohut, continue the line of neo-Freudians.
      
      Theories of object relations emphasize the importance for personal development of very early relationships between children and their objects of love, usually the mother and the primary figures that provide the child with care. Especially critical in a person's life is how primary figures provide support, protection, acceptance and approval, or, in other words, satisfy the child’s physical and psychological needs. The nature of these object relations has an important impulse for personal development. In its development, a healthy person goes from a reliable early attachment to the mother or her substitutes through a gradual distance from the object of attachment to the ability to build relationships with other people as an independent individual. Disrupted object relationships can create problems that interfere with personal development processes and lead to inadequate self-esteem, difficulties in interpersonal relationships, or more serious mental disorders.
   
   
   
   
   
   

Behavioral approach

1. 
   
   1. Behavioral therapy as a systematic approach to the diagnosis and treatment of psychological disorders emerged relatively recently - in the late 50s. In the early stages of development, behavioral therapy was defined as an application of the “modern theory of learning” to the treatment of clinical problems. The concept of "modern theories of learning" then belonged to the principles and procedures of classical and operant conditioning.
      
      The theoretical source of behavioral therapy was the concept of the behaviorism of the American zoopsychologist Watson and his followers, who understood the enormous scientific significance of Pavlovian theory of conditioned reflexes, but interpreted them and used them mechanistically. According to the behaviorists, human psychic activity should be investigated, like in animals, only by registering external behavior and exhausted by establishing the relationship between stimuli and body reactions, regardless of the influence of the personality. In attempts to mitigate the obviously mechanistic positions of their teachers, neobieviorists later began to consider between stimuli and responses the so-called “intermediate variables” - the effects of the environment, needs, skills, heredity, age, past experience, etc., but still left the individual unattended. In fact, behaviorism followed Descartes' long-held doctrine of "animal machines" and the concept of the 18th century French materialist Lametry about "man-machine."
      
      Based on the theories of learning, behavioral therapists viewed human neuroses and personality anomalies as an expression of non-adaptive behavior developed during ontogenesis. Volpe defined behavioral therapy as “the application of experimentally established principles of learning for the purpose of changing non-adaptive behavior. Non-adaptive habits are weakened and eliminated, adaptive habits arise and strengthen. " At the same time, the clarification of complex mental causes of the development of psychogenic disorders was considered unnecessary.
      
      Over the years, optimism regarding the particular efficacy of behavioral therapy has become weakened everywhere, even among its prominent founders. So, Lazarus, a student and former closest associate of Volpe, objected to his teacher’s assertion that behavioral therapy was supposedly entitled to challenge other types of treatment as the most effective. Other authors reported on the reduction of the range of disorders with a favorable reaction to this form of treatment, recognizing the success of behavioral methods mainly in simple phobias or inadequate intelligence, when the patient is not able to formulate their problems in a verbal form.
      
      Critics of the isolated use of methods of behavioral therapy see its main defect in the one-sided orientation to the action of the elementary technique of conditional reinforcements. The fundamental disadvantage of the theory of behavioral therapy is not the recognition of the important role of the conditioned reflex in the neuropsychic activity of a person, but the absolutization of this role.
      
      In recent decades, behavioral therapy has undergone significant changes, both in nature and in scope. This is due to the achievements of experimental psychology and clinical practice. Now behavioral therapy cannot be defined as an application of classical and operant conditioning. Different approaches to behavioral therapy today differ in the degree of use of cognitive concepts and procedures.
   
   
   
   
   
   

Cognitive therapy

1. 
   
   1. The beginning of cognitive therapy is associated with the activities of George Kelly. In the 1920s, George Kelly used psychoanalytic interpretations in his clinical work. He was amazed at how easily patients accepted Freudian concepts, which Kelly himself found absurd. As an experiment, Kelly began to vary the interpretations he gave to patients within the most diverse psychodynamic schools.
      
      It turned out that patients equally accept the principles proposed to them and are eager to change their lives in accordance with them. Kelly concluded that neither the Freudian analysis of children's conflicts, nor even the study of the past as such is of decisive importance. According to Kelly, Freud's interpretations turned out to be effective, as they shook the way of thinking that was usual for patients and gave them the opportunity to think and understand in a new way.
      
      The success of clinical practice with a variety of theoretical approaches, according to Kelly, is explained by the fact that during the course of therapy there is a change in how people interpret their experience and how they look to the future. People become depressed or anxious because they fall into the trap of rigid, inadequate categories of their own thinking. For example, some people believe that authority figures are always right, so any criticism from an authority figure acts on them depressingly. Any technique that leads to a change in this belief, whether it is based on a theory that connects such a belief with the oedipal complex, with the fear of losing parental love or the need for a spiritual leader, will be effective. Kelly decided to create techniques for the immediate correction of inadequate ways of thinking.
      
      He suggested that patients realize their beliefs and test them in action. He also used role-playing games. Kelly came to the conclusion that the core of neurosis is non-adaptive thinking. The problems of the neurotic lie in real ways of thinking, and not in the past. It is the task of the therapist to ascertain unconscious categories of thinking that lead to suffering, and to learn new ways of thinking.
      
      Kelly was one of the first psychotherapists who tried to directly change the thinking of patients. This goal underlies many modern therapeutic approaches that are combined with the concept of cognitive therapy.
      
      At the present stage of development of psychotherapy, the cognitive approach in its pure form is almost not practiced: all cognitive approaches use behavioral techniques to a greater or lesser degree. This is also true of A. Ellis's rational emotive therapy and A. Beck's “cognitive therapy”.
   
   
   
   
   
   

The emergence of cognitive behavioral therapy

1. 
   
   1. In experimental studies in the field of cognitive psychology, in particular Piaget’s studies, clear scientific principles were formulated that could be applied in practice. Even the study of the behavior of animals showed that one should take into account their cognitive abilities to understand how they learn.
      
      In addition, there was an understanding that behavioral therapists, without knowing it, using the cognitive abilities of their patients. Desensitization, for example, uses the patient's willingness and ability to imagination. Social skills training is not really a condition: patients learn not specific responses to stimuli, but a set of strategies needed to cope with situations of fear. The use of imagination, new ways of thinking and applying strategies involves cognitive processes.
      
      A number of common features have emerged from behavioral and cognitive therapists:
      
      1. Both those and others are not interested in the causes of disorders or past patients, but deal with the present: behavioral therapists focus on actual behavior, and cognitive therapists on what people think about themselves and about the world in the present.
      
      2. Both see the therapy as a learning process, and the therapist as a teacher. Behavioral therapists teach new ways of behavior, and cognitive therapists teach new ways of thinking.
      
      3. Both give their patients homework so that they can practice outside the therapeutic environment what they have received during the therapy sessions.
      
      4. Both those and others prefer the practical, devoid of absurdity (meaning psychoanalysis) approach, not burdened with complex theories of personality.
   
   
   
   
   
   

Phenomenological approach

1. 
   
   1. According to the phenomenological approach, each person has a unique ability to perceive and interpret the world in his own way. In the language of philosophy, the mental experience of the environment is called a phenomenon, and the study of how a person experiences reality is called phenomenology.
      
      Proponents of this approach are convinced that not instincts, internal conflicts or environmental stimuli determine a person’s behavior, but his personal perception of reality at any given moment. Man is not an arena for solving intrapsychic conflicts and not behavioral clay, from which, thanks to learning, a person is molded, but, as Sartre said: "Man is his choice." People control themselves, their behavior is determined by the ability to make their choice - to choose, how to think, and how to act. These choices are dictated by the unique perception of man of the world. Phenomenological psychologists consider even deep depression not as a mental illness, but as a sign of an individual's pessimistic perception of life.
      
      In fact, the phenomenological approach leaves beyond its consideration the instincts and learning processes that are common to both humans and animals. Instead, the phenomenological approach focuses on such specific mental qualities that distinguish man from the animal world: consciousness, self-awareness, creativity, the ability to make plans, make decisions and take responsibility for them. For this reason, the phenomenological approach is also called humanistic.
      
      Another important assumption of this approach is that every person has an innate need for realizing their potential - in personal growth - although the environment may block this growth. People are naturally prone to kindness, creativity, love, joy, and other higher values. The phenomenological approach also implies that no one can truly understand another person or his behavior unless he tries to look at the world through the eyes of this person. Phenomenologists, therefore, believe that any human behavior, even one that seems strange, is meaningful to the one who discovers it.
      
      Emotional disturbances reflect the blocking of the need for growth (self-actualization) caused by distortions of perception or lack of awareness of the senses. Гуманистическая психотерапия основывается на следующих предположениях:
      
      1. Лечение есть встреча равных людей («энкаунтер»), а не лекарство, прописываемое специалистом. Оно помогает пациенту восстановить свой естественный рост и чувствовать и вести себя в соответствии с тем, какой он есть на самом деле, а не с тем, каким он должен быть, по мнению других.
      
      2. Улучшение у пациентов наступает само по себе, если терапевт создает правильные условия. Эти условия способствуют осознанности, самопринятию и выражению пациентами своих чувств. Особенно тех, которые они подавляли и которые блокируют их рост.
      
      Как и при психодинамическом подходе, терапия способствует инсайту, однако в феноменологической терапии инсайт — это осознание текущих чувств и восприятий, а не бессознательных конфликтов.
      
      3. The best way to create these right (ideal) conditions is to establish relationships in which the patient feels unconditional acceptance and support. Therapeutic changes are achieved not as a result of the use of specific techniques, but as a result of the patient experiencing this relationship.
      
      4. Patients are fully responsible for choosing their own way of thinking and behavior.
      
      The most well-known forms of phenomenological therapy are the “client-centered therapy” of Carl Rogers and the “gestalt therapy” of Frederick Perls.
      
      Карл Роджерс практиковал психодинамическую терапию в 30-х годах. Но скоро он начал сомневаться в ее ценности. Особенно не импонировало ему быть беспристрастным экспертом, который «понимает» пациента. Он убедился в том, что менее формальный подход более эффективен, и начал использовать так называемую «недирективную терапию», позволяя своим пациентам самим решать, о чем говорить и когда, без направления, оценки или интерпретации со стороны терапевта. Этот подход сейчас называется «клиент-центрированной терапией», чтобы подчеркнуть роль клиента. Фундаментом лечения Роджерса является создание отношения, характеризуемого тремя важными и взаимосвязанными позициями («триада Роджерса»): безусловное позитивное отношение, эмпатия, конгруэнтность.
      
      Роджерс замечал, что в процессе клиент-центрированной терапии клиенты становятся не только более уверенными в себе, но они начинают лучше осознавать свои подлинные чувства, принимать себя, держаться более комфортно и естественно с другими людьми, в большей степени полагаться на собственную оценку становятся более продуктивными и спокойными.
      
      ^ Разновидностью психодинамической психотерапии является наша отечественная личностно-ориентированная (реконструктивная) психотерапия, разрабатываемая в Психоневрологическом институте им. Бехтерева, теоретической основой которой служит психология отношений В. Н. Мясищева.
      
      The main goal of this model is the reconstruction of the system of relationships, disturbed in the process of personal development under the influence of social factors, primarily distorted interpersonal relations in the parental family. The broken relationship system does not allow a person to rationally solve intrapsychic conflicts that arise in a difficult life situation, which leads to the emergence of a neurosis. Awareness of conflict is one of the important tasks in the process of psychotherapy. The concept of the personality of V.N. Myasishchev and the concept of personality-oriented (reconstructive) psychotherapy are described in detail in separate lectures.
      
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Taking into account the main factors of psychotherapy outside of its specific areas and forms, it is possible to single out the emerging models of integrative psychotherapy: humanistic, instrumental-interactional and instrumental-technical (Tashlykov V.A 1992). In the humanistic model of integrative psychotherapy, empathic “psychotherapist-patient” communication can be recognized as a decisive factor in her virginity. In the instrumental-interactional model, preference is also given not to technical methods, but to using the “psychotherapist – patient” relationship as a therapeutic tool, however, the psychotherapist takes a more active position and takes on a certain share of responsibility and initiative. The instrumental-technical model of integrative psychotherapy, compared with the previous one, is characterized by a further increase in the activity of the psychotherapist in the relationship with the patient, a more structured process of psychotherapy; it emphasizes the use of various technical methods and methods. In this case, alternative forms of treatment are discussed with the patient, the goals of psychotheravia and its methods, treatment plan, duration and expected results of therapy are coordinated.

The choice of a specific method of psychotherapy, the formulation and implementation of psychotherapeutic goals and objectives in the case of its medical model are determined by the mutual influence of specific clinical indicators of the patient and the disease, the characteristics of his personality and other psychological characteristics, the level of the patient’s socio-psychological adaptation synthesized in a multidimensional diagnosis, and organizational form of psychotherapy.

In the Russian-language literature, an increasing popularity with regard to the appointment of psychotherapy is gaining an idea of ​​its three levels of conduct: 1) professional psychotherapy is carried out by a psychotherapist who is the attending physician and independently leads the patient; 2) psychotherapy as an auxiliary method can be carried out both by a professional psychotherapist and by a narrow specialist; 3) psychotherapy in general medical practice is carried out by all doctors, which allows to implement a biopsychological approach in medicine. Clear definition of level II. contributes to the reasonable formulation of its goals and objectives, while both underestimating and overestimating the possibilities of P. affect the effective in treatment and image of the psychotherapist and psychotherapeutic service.

In academic psychotherapy, there is a widespread point of view on the desirability of distinguishing the whole variety of psychotherapy methods. At the same time, as Leder points out, terms such as restraining and liberating, supporting and integrative, symptomatic and causal, superficial and deep, cognitive and emotional, mechanistic and humanistic, dynamic, behavioral, empirical psychotherapy, etc. are used.

There is no single generally accepted classification of methods of psychotherapy. Aleksandrovich (Aleksandrowicz JW, 1979) made an attempt to analyze all the variety of meanings that use the concept of the method of psychotherapy: 1) methods that have the character of a technician: 2) methods defining conditions that contribute to the achievement and optimization of the goals of psychotherapy; 3) methods within the meaning of the instrument that we use in the course of the psychotherapeutic process; 4) methods in the meaning of therapeutic intervention (interventions).

There are different methods of psychotherapy, revealing the causes of conflicts, and methods that do not disclose them (referring to the different positions of psychotherapists with respect to unconscious complexes and conflicts). Methods that reveal the causes of conflicts are basically identical to psychoanalysis or methods oriented to psychoanalysis; they suggest that the unconscious component of the personality plays an important role. The distinction between “big” and “small” P. is widely distributed. They include methods of psychoanalysis and schools close to it, secondly rational psychotherapy (conversations with patients), as well as methods based on suggestion and relaxation. Depending on the conditions in which psychotherapy is conducted, and the medical training of the therapist, there is a distinction between psychotherapy by a specialist doctor and psychotherapy by a general practitioner and general intern; in addition, there are psychotherapy conducted in an outpatient setting, and psychotherapy carried out in a hospital (the latter involves the characteristic conditions of treatment and the use of certain methods of influence). In practice, the difference is also important group psychotherapy from individual, since each of them is associated with certain prerequisites in relation to the indications, the preparation of a psychotherapist and the technique of conducting sessions.

None of the existing methods is the best, different methods have different goals and are not applicable to all patients, but to certain groups of patients. Their choice depends on the psychotherapist - on his personality, level of training and theoretical orientation.

In the domestic literature, the use of the concepts of the method, method, form, method, and psychotherapy technique is primarily subjective, which could not but affect their systematics. The situation was worsened by poor awareness and ideological orientation of domestic psychotherapy, and therefore many methods widely used throughout the world were not included in the classification schemes. VE Rozhnov (1983) divided psychotherapy into general and particular, or special. General psychotherapy includes a complex of mental effects on the patient, aimed at increasing his strength in the fight against the disease, at creating a protective-restorative regime that excludes psychological traumatization and iatrogeny. At the same time, psychotherapy is an auxiliary tool, creating a general background against which other types of treatment are applied (medication, physiotherapy, etc.). In 1985 BD Karvasarsky has already divided psychotherapy into: 1) methods of personality-oriented psychotherapy; 2) methods of suggestive psychotherapy and 3) methods of behavioral (conditioned-reflex) psychotherapy.

Despite the various classification divisions, it is customary to consider psychotherapy as symptom-based and personality-oriented. The first traditionally includes hypnotherapy, autogenic training, various types of suggestion and self-hypnosis, and other psychotherapy, focused on significant personality changes, based on the main trends of modern psychology, and accordingly dynamic, behavioral and humanistic directions stand out.

Recently, there has been an increasing integration of psychotherapy into healthcare in Russia, the main systems for providing psychotherapeutic care are being developed, which envisages the development of three main forms of organization of psychotherapeutic services: 1) a psychotherapeutic room, 2) a psychotherapeutic department; 3) psychotherapeutic center. Improvement of the provision of psychotherapeutic care is expected on the basis of the development of special medical technologies that allow with. the attraction of a flexible management structure and coordination to significantly improve the quality of psychotherapeutic services, to overcome the fragmentation and disintegration of institutions and doctors that provide psychotherapeutic assistance inherent in the organization of psychotherapy (Nazyrov R. K., 1995; Yeresko D. B., Kondinsky A. G. 1995). However, the latter systems need well-trained specialists. To this end, in 1995 (for the first time in Russia), the Federal Center for Psychotherapy of the Ministry of Health developed requirements for an educational standard that defines minimum terms for established types of training and supervision, with the transition in the educational system of psychotherapists from mainly information training to more advanced forms of learning skills ; training at the level of the clinical use of psychotherapy; training, taking into account the individual characteristics of the individual psychotherapist.

The achievements of psychotherapeutic science are obvious. As the most important events for Russia in the field of psychotherapy over the past two decades, it is possible to note the overcoming of its own limitations and the beginning of active cooperation with psychotherapeutic centers in many countries. The activities of Russian psychotherapists have almost completely included all methods and approaches known in the world of psychotherapy; psychotherapeutic science is being actively developed, the first and quite distinct steps in the development of other (except for St. Petersburg) schools of psychotherapy with their own methodology and practice are outlined. An undoubted success in the field of psychotherapy was the introduction in the late 90s. teaching psychotherapy and medical psychology in medical schools, the movement to improvement of psychotherapy through the use of brigade forms of work with the participation of a psychiatrist, a psychotherapist, a medical psychologist and a social work specialist in the provision of psychotherapeutic assistance. An important event was the emergence of a larger number of professional communities of psychotherapists. The immediate tasks are the further development of education in the field of psychotherapy, the introduction of a barrier to penetration into psychotherapy by untrained specialists, the creation of conditions for cooperation between representatives of medical and psychological psychotherapy, for serious and fundamental developments in psychotherapy and related scientific fields.

Literature.

Main literature.

1. Yezhova N.N. The workbook of a practical psychologist. - Rostov n / D: Phoenix, 2008.
2. Malkina-Pykh I.G. Handbook of practical psychologist. - M.: Eksmo, 2008.
3. Handbook of practical psychologist. / Comp. S.T. Posokhova, S.L. Solovyov. - M .: AST: KEEPER; SPb .: Owl, 2008.

Additional literature.

1. Feidimen D., Freyger R. Theory and practice of student-centered psychology. - M., 1995.
2. Adler A. Practice and theory of individual psychology. - M. 1995.
3. Sidorenko E.V. Experimental group psychology. - SPb., 1993.
4. Adler A. Individual psychology. / History of foreign psychology. 30-60-ies of XX century. (texts). - M., 1986.
5. Vitels S. Freud: his personality, teaching and school. Chapter X. A. Adler. - L., 1991.
6. Draykurs R., Zoltz V. Happiness of your child. - M., 1986.
7. Christensen OK, Thomas K.R. Draycurs and the search for equality. - M., 1992.