八月初的一个星期四，心理学家史蒂文·库尔茨正在为他的客户玛丽亚准备一次治疗。玛丽亚是一位冷静而开朗的女士，留着长长的黑发，几个月来，她一直在纽约市儿童心理研究所与她六岁的儿子瑞恩（化名）一起接受培训，为这一天做好准备。她的目标似乎很简单：哄瑞恩听从一个简单的指令。但瑞恩不太听从指挥。
玛丽亚和瑞恩正在进行一种名为亲子互动疗法（PCIT）的家长培训，旨在纠正儿童的对抗行为。到目前为止，玛丽亚一直让瑞恩选择他们的活动。今天，玛丽亚将第一次选择要做的事情。
库尔茨告诉玛丽亚，一次只下达一个指令。她练习道：“你能给我蓝色的积木吗？” 心理学家纠正她：“给我蓝色的积木。” 指令必须是直接的，以避免任何选择的暗示。如果他服从，立即表扬；当他不服从时，说：“如果你不把蓝色的积木给我，你就必须坐在静坐椅上。” 如果他从椅子上下来，妈妈的台词是：“在你被允许之前，你就从椅子上下来了。如果你再次从椅子上下来，你将不得不去静坐室。”
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“就像《主祷文》一样，措辞总是相同的。” 库尔茨解释说。“用相同的语调说出来。”
库尔茨移走了房间里现在用来存放玩具的箱子；他认为，它们更有可能被用作武器，而不是用来清理。另一个问题是瑞恩。他在楼下的电脑旁，想待在那里。当玛丽亚把这个瘦弱、黑发的男孩拉进房间时，他正怒气冲冲。“这很无聊！” 他喊道。
库尔茨向瑞恩解释了新规则。“到目前为止，一直是你在选择活动。” 今天，库尔茨说，“妈妈将轮流和你一起玩。”
“嘿——我有这辆车。我有这辆车！” 男孩打断了他的话。他拿着房间里的一辆玩具车。库尔茨继续说：“当妈妈选择活动时，你必须听从她的指示，这非常重要。如果你不听，她会告诉你去坐那把椅子。如果你坐在那把椅子上，你就可以回来和她一起玩。如果你不坐，你就必须去这个房间。” 他指着房间角落里一个狭窄的围栏的门。“不，我会待在这里！” 瑞恩喊道。
库尔茨退出房间，并在单向玻璃墙后面的一个小观察室里安顿下来。库尔茨可以观察这对母子，但他们看不到他。玛丽亚将通过她戴着的耳机收听他的指示。
玛丽亚告诉瑞恩，他们的特殊时光开始了。“你想选择一项活动吗？” 她问道。瑞恩在房间里乱扔玩具。“稍后再下达所有指令，” 库尔茨建议。“他在做什么？” 治疗要求叙述孩子的行为，以显示兴趣并帮助孩子将注意力集中在任务上。“现在他在玩汽车，” 玛丽亚说。
汽车在房间里飞来飞去。砰！ 撞击！ 砰！ 玛丽亚没有责骂、喊叫，甚至没有看瑞恩。她直视前方。“寻找他做你喜欢的事情的那一瞬间，” 库尔茨建议。“当他停止扔东西时……就一秒钟……”
大多数年幼的孩子有时会故意不服从或发脾气。然而，当每一个日常任务——系安全带、在拐角处牵手、穿衣服——都引发对抗时，父母通常会寻求帮助。PCIT 专为两到七岁的儿童设计，改变了父母回应孩子的方式。它加强了亲子关系，同时为合作提供了 consistent 的规则和奖励。
PCIT 不是治疗某种 disorder，而是更广泛地针对 disruptive behavior，其范围从顶嘴到严重的攻击行为。Disruptive behavior 是幼儿最常见的心理健康问题，是几种不同诊断的特征，包括 oppositional defiant disorder (ODD)——极度的不服从和对权威人物的敌意——以及 conduct disorder，在这种 disorder 中，孩子们无视规则、打架、撒谎、偷窃并从事其他令人震惊的坏行为。
瑞恩患有 attention-deficit hyperactivity disorder (ADHD)，这通常会引发行为问题。他与其说是被 defiance 驱使，不如说是 inexorably 地被当下最吸引人的东西所吸引——电视节目、热巧克力、游乐场，甚至睡眠。他对追求当前活动的需要导致他拒绝 conflicting 的请求或 demands。每天早上，玛丽亚都会强行把瑞恩从床上拉起来并给他穿衣服。当瑞恩的祖母放学后照顾他并关掉电视时，瑞恩生气地把所有可用的书本和玩具扔到地板上。
超过 100 篇研究文章，包括八项 randomized trials，已经证明 PCIT 在改善此类反应方面非常有效，而且疗效持久。利害关系超越了家庭 dynamics。有 significant behavior 问题的幼童 later on 有 serious antisocial behavior 的 high risk。“之前的研究非常清楚：如果 early child behavior 问题没有得到纠正，它们很可能会 escalate 到更 destructive 和 intractable 的行为，” 疾病控制与预防中心的 developmental psychologist 詹妮弗·怀亚特·卡明斯基说。“Preventing 青少年的 risky 和 violent behavior 是一个重要的 public health issue。”
由于其 scientific backing，PCIT 正在获得 international recognition，并在全国各地的诊所中迅速取得进展——主要是在特拉华州、加利福尼亚州、卡罗来纳州、宾夕法尼亚州、俄克拉荷马州和爱荷华州——这些州正在实施 large-scale training programs。当 PCIT International（一个成立于 2009 年的组织）推出其 planned protocol 以 certifying therapists 时，这种疗法很可能会得到更广泛的 disseminated。Certification 将使 interested parents 能够在 Internet 上找到 qualified therapists。
Recent adaptations 已经 retrofitted 了这种 approach，以 suit older children，并且——taking advantage of its emphasis on parenting skills——prevent relapse in abusive parents。PCIT 也为 controlling more moderate forms of troublesome behavior in children 提供了 useful tactics。“这是一种改变你的 vocabulary 并以 positive manner 与你的孩子交谈的方式，” 特拉华州预防和行为健康服务部门的 clinical psychologist 约书亚·马塞说。库尔茨补充说，“这是应该给父母的手册。”
“你的想象力像你的机器人一样飞翔”
PCIT 起源于 1970 年代初期，当时 Sheila M. Eyberg 是俄勒冈健康科学大学的 clinical psychology intern。她用 play therapy 治疗行为问题，在这种 therapy 中，therapist 指导孩子在 playtime 期间描述他或她的 emotions，以此作为 self-acceptance 的途径。Eyberg 注意到她的 charges “似乎 calm down 了，‘self-correct’ 了，并试图 please me，” 她在 2004 年的 PCIT Pages: The Parent-Child Interaction Therapy Newsletter 中写道。但是，她写道，“他们的 parents 没有 reporting similar experiences at home。Nor were they reporting changes in their children's behaviors。” 孩子们没有与他们的 parents bonding，而是与 Eyberg connecting。
Psychologist Constance Hanf，当时也在 O.H.S.U.，正在 piloting 一种 approach，旨在 address 这些 concerns。她正在 training mothers 充当她们 children 的 therapists，这些 children 有 developmental disabilities。Hanf 的 program 的 key target 是 parent-child bond。根据 attachment theory，这种 bond 提供了一个 secure base，孩子可以从中 explore the world，并帮助孩子 control 他或她的 emotions。在 Hanf 的 therapy 中，parents built 这种 connection，同时 playing 一个 child's choosing 的 game。作为 Hanf 的 students 之一，Eyberg constructed PCIT around her teacher's scaffold。
去年夏天，劳拉（化名）是一位 fun-loving young mother，在她的 therapy sessions 之一中 textbook demonstration 了 PCIT 的这个 element。她的儿子，我称之为加布里埃尔，一个 light brown、curly hair 的 small six-year-old，刚刚用 magnets 创建了一个 robot。
“哦，你选择玩 magnets！” 劳拉说。“Beautiful robot。I love it。”
“现在它是一座 castle，” 加布里埃尔谈到他的 creation 时说。加布里埃尔患有 ODD。
“It's so smart——你把 robot converted 成一座 castle，” 他的 mother 说。
加布里埃尔伸出舌头。“You're sticking out your tongue，” 劳拉叙述道。
“People hate him so he started to transform，” 加布里埃尔谈到他的 robot 时说。
“That's very smart，” 他的 mother compliments 道。“Thank you for telling me the whole story。” 加布里埃尔开始用 funny、robotic voice 说话。劳拉模仿他。
“你的想象力像你的 robot 一样飞翔，” 劳拉说。“You can come up with different designs like this。It's amazing to me。”
劳拉描述和 imitates 加布里埃尔的行为，repeats 他说的话——所有这些都让 child lead——并且 acts happy 和 relaxed。劳拉的 behavioral descriptions 也 show 她 is interested，demonstrate proper speech，并 help 加布里埃尔 stay focused on the task。劳拉 frequently praises 这个男孩，telling him exactly what she likes about what he is doing。In addition，parents are told to ignore minor misbehavior，so that the child learns that only behaving appropriately earns him attention。劳拉已经 met the criteria for mastery：in five minutes，she issues five behavioral descriptions，five reflections，15 praises，and fewer than three commands，questions and criticisms。
PCIT 的 second phase，玛丽亚和瑞恩刚刚开始的 phase，是 directed at limit setting 和 discipline。它也是 based on Hanf's therapy，其中 included 一个 geared toward controlling behavior 的 component。Parents guide child with clear instructions 和 consistent consequences，such as praise for compliance 和 time-out for disobedience。Parents graduate from this phase when three quarters of their commands are direct and the child complies with all of them。
劳拉 close 了。加布里埃尔 complies with some but not all of her requests。当劳拉说她想 do a puzzle 时，加布里埃尔 protests：“I am tired of listening！I don't want to do this。Can we go out？” 加布里埃尔 does not work on the puzzle for long，but he does eventually agree to sit next to 劳拉 and put the pieces away——and he never needs to sit in the time-out chair，although 劳拉 threatens to put him there。
加布里埃尔和劳拉 have already come a long way。Earlier in the year，加布里埃尔 had been very unhappy and angry。He acted aggressively toward 劳拉 and refused to obey her。“Get ready for bed or get ready for school……to get him to do anything was very，very hard，” 劳拉 recalls。Now 加布里埃尔 complies with her requests much more often。“When I ask him to turn off the iPad，he hands it to me，” 劳拉 says。“He knows that if he doesn't，there's a consequence。”
在 1998 年 published 的 therapy 的 landmark test 中，Eyberg（现在在佛罗里达大学）和她的 colleagues 给 22 个有 ODD 的三到六岁 children 的 families 提供了 PCIT，并将其他 27 个 families assigned to a waitlist。The parents who received treatment interacted with their children more positively，praising them more and criticizing them less，than those on the waitlist。The children of the parents who participated in PCIT，in turn，were more likely to do what was asked of them。These parents noted large improvements at home as well，rating their child's behavior within the normal range，on average，by the end of treatment。Many of these kids no longer qualified for a diagnosis of ODD。A 2003 study revealed that the treated children became even easier to handle in the following three to six years，perhaps because children and parents reinforce one another's good behavior over time。
在 2007 年的 meta-analysis（statistical review）of 13 studies of PCIT 中，psychologists Rae Thomas 和 Melanie J. Zimmer-Gembeck（当时都在澳大利亚格里菲斯大学）confirmed that the therapy is linked to significantly improved parenting and reduced negative behavior in kids。It boosts warmth from parents，decreases their hostility and reduces their stress。It also diminishes aggression and oppositional behavior among children。
PCIT 的 success is thought to stem，in part，from its emphasis on rehearsal of a particularly relevant set of skills。在 2008 年 published 的 77 investigations of parent-training programs 的 meta-analysis 中，卡明斯基和她的 colleagues found that requiring parents to practice the appropriate actions with their children during the training sessions seemed to be critical to correcting parent behavior。卡明斯基的 team 也 noted that parent proficiency tended to improve whenever moms and dads were taught to talk to their kids about emotions and to effectively listen to them。In addition，the researchers identified the two essential elements to boosting children's behavior ratings：instructing parents to interact positively with their children——expressing enthusiasm and following the child's lead——and to respond consistently to a child's actions。
儿童保护
Sometimes the child is not the problem；the parent is。Parenting education and training has been a staple in child welfare for decades。Typically parents discuss their experiences and strategies in groups，but such conversations often fail to change the family dynamic，and parental neglect or abuse persists。
In the early 2000s，Mark Chaffin（俄克拉荷马大学健康科学中心的 child abuse researcher）wanted to test PCIT with such parents on the grounds that teaching skills might be more effective than discussing concepts。The state child welfare system sent him 110 adults who had been reported multiple times for physical abuse of their children。The parents received 12 to 14 one-hour sessions at the university's large PCIT center。In addition，Chaffin required these mothers and fathers to participate in a motivational exercise。“If your five-year-old is driving you crazy，you are fairly motivated，” Chaffin explains。“But we were concerned that people coming from child welfare would not be happy to be sent to a program。” In Chaffin's program，parents were asked to consider their parenting goals and whether their actions aligned with those goals。
The combination approach worked。More than two years later，only 19 percent of the parents who had received both PCIT and the motivational interview had been reported again for abuse——compared with 49 percent of those who had been assigned to a standard parenting group，according to a 2004 study by Chaffin and his colleagues。“We got large effect sizes in reduction of child welfare recidivism，” something that is hard to budge，Chaffin says。
在 2011 年 published 的 follow-up trial 中，Chaffin's team extended these results to more severe cases of abuse and neglect and a more realistic therapeutic setting：a small inner-city agency under contract with the state's child welfare system。Among 192 parents who had averaged six prior referrals to child welfare，a motivational interview along with PCIT led to a recidivism rate of around 17 percent two and a half years later，compared with about 65 percent for those who received standard group therapy along with a motivational interview。“Even if you are motivated，typical group therapy doesn't give you a lot of benefit，” Chaffin concludes。
The children involved in Chaffin's studies ranged from four to 12 years old，so he and his colleagues adapted the treatment to older kids。Time-outs were replaced with logical consequences——such as taking away objects that a child is actively misusing——and loss of privileges。And praise was less demonstrative。Instead of exclaiming “What a nice tower！” to a child playing Legos，a father might challenge his 11-year-old son to a tower-building race。“Oh，you're killing me！” the dad might praise。In a 2012 case study，Eyberg and her colleagues also found that PCIT greatly improved the newly aggressive and oppositional behavior of an 11-year-old who had suffered a traumatic brain injury from a gunshot wound。
“请递给我粉红色的甜甜圈”
PCIT holds useful lessons for more ordinary circumstances as well：ignore bad behavior，praise good；tell a child what to do rather than what not to do；phrase commands as such，not as questions or suggestions。Indeed，Eyberg and her colleagues found that two abbreviated versions of the technique significantly improved the behavior of 30 three- to six-year-olds whom their mothers had characterized as having moderate behavior problems。Both a four-session group intervention and written materials describing how to practice PCIT garnered similar benefits，suggesting that hands-on coaching may not be necessary in milder cases。
回到儿童心理研究所，瑞恩已经 calmed down 了，但 balks at the suggestion that he play his mother's game。Soon he is sent to the time-out chair，but he will not sit there voluntarily and gets up repeatedly。Then，before he can be moved to the time-out room，he kicks his mother and pushes her into the room，locking her inside，and then knocks over all the big metal chairs。库尔茨 intervenes。
For more than an hour，瑞恩 goes from the time-out room to the time-out chair and back again，crying and protesting。“I'll kill you！I'll kill you！You're nuts！” he shouts。玛丽亚 remains calm。She smiles and laughs to help ease the tension。
Finally，瑞恩 elects to stay in the chair，so 玛丽亚 attempts a command。She tells 瑞恩 to come sit next to her。“To do what？” he challenges。He is sent back to the chair。Yet again he stays there，whimpering。Twenty minutes later，in response to a period of relative silence，玛丽亚 says。“You're sitting quietly。Are you ready to come and sit with me？” “Yes。” He walks over to her，sobbing softly。
“Okay。Please hand me the pink doughnut。” He finds the pink doughnut from a smattering of plastic toys spread out on the table——and hands it to her。
“Thank you for doing what I told you。” She pets his face and smiles。He is still teary。
“Now please hand me the banana。” He does。
“Yay！Good listening。” She kisses him。瑞恩 brings his mom one more item，a plastic potato chip，before 库尔茨 ends the session。
That afternoon 瑞恩 passed another milestone。When 库尔茨 enters the room，玛丽亚 flashes a wide smile。She gives 库尔茨 a thumbs-up，and the two exchange a high five。瑞恩 does not feel like celebrating，however。“I had a very hard day，” he sighs。