八月初的一個星期四，心理學家史蒂文·庫爾茨正在為他的客戶瑪麗亞準備一次治療。瑪麗亞是一位冷靜而開朗的女士，留著長長的黑髮，幾個月來，她一直在紐約市兒童心理研究所與她六歲的兒子瑞恩（化名）一起接受培訓，為這一天做好準備。她的目標似乎很簡單：哄瑞恩聽從一個簡單的指令。但瑞恩不太聽從指揮。
瑪麗亞和瑞恩正在進行一種名為親子互動療法（PCIT）的家長培訓，旨在糾正兒童的對抗行為。到目前為止，瑪麗亞一直讓瑞恩選擇他們的活動。今天，瑪麗亞將第一次選擇要做的事情。
庫爾茨告訴瑪麗亞，一次只下達一個指令。她練習道：“你能給我藍色的積木嗎？” 心理學家糾正她：“給我藍色的積木。” 指令必須是直接的，以避免任何選擇的暗示。如果他服從，立即表揚；當他不服從時，說：“如果你不把藍色的積木給我，你就必須坐在靜坐椅上。” 如果他從椅子上下來，媽媽的臺詞是：“在你被允許之前，你就從椅子上下來了。如果你再次從椅子上下來，你將不得不去靜坐室。”
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“就像《主禱文》一樣，措辭總是相同的。” 庫爾茨解釋說。“用相同的語調說出來。”
庫爾茨移走了房間裡現在用來存放玩具的箱子；他認為，它們更有可能被用作武器，而不是用來清理。另一個問題是瑞恩。他在樓下的電腦旁，想待在那裡。當瑪麗亞把這個瘦弱、黑髮的男孩拉進房間時，他正怒氣衝衝。“這很無聊！” 他喊道。
庫爾茨向瑞恩解釋了新規則。“到目前為止，一直是你在選擇活動。” 今天，庫爾茨說，“媽媽將輪流和你一起玩。”
“嘿——我有這輛車。我有這輛車！” 男孩打斷了他的話。他拿著房間裡的一輛玩具車。庫爾茨繼續說：“當媽媽選擇活動時，你必須聽從她的指示，這非常重要。如果你不聽，她會告訴你去坐那把椅子。如果你坐在那把椅子上，你就可以回來和她一起玩。如果你不坐，你就必須去這個房間。” 他指著房間角落裡一個狹窄的圍欄的門。“不，我會待在這裡！” 瑞恩喊道。
庫爾茨退出房間，並在單向玻璃牆後面的一個小觀察室裡安頓下來。庫爾茨可以觀察這對母子，但他們看不到他。瑪麗亞將透過她戴著的耳機收聽他的指示。
瑪麗亞告訴瑞恩，他們的特殊時光開始了。“你想選擇一項活動嗎？” 她問道。瑞恩在房間裡亂扔玩具。“稍後再下達所有指令，” 庫爾茨建議。“他在做什麼？” 治療要求敘述孩子的行為，以顯示興趣並幫助孩子將注意力集中在任務上。“現在他在玩汽車，” 瑪麗亞說。
汽車在房間裡飛來飛去。砰！ 撞擊！ 砰！ 瑪麗亞沒有責罵、喊叫，甚至沒有看瑞恩。她直視前方。“尋找他做你喜歡的事情的那一瞬間，” 庫爾茨建議。“當他停止扔東西時……就一秒鐘……”
大多數年幼的孩子有時會故意不服從或發脾氣。然而，當每一個日常任務——系安全帶、在拐角處牽手、穿衣服——都引發對抗時，父母通常會尋求幫助。PCIT 專為兩到七歲的兒童設計，改變了父母回應孩子的方式。它加強了親子關係，同時為合作提供了 consistent 的規則和獎勵。
PCIT 不是治療某種 disorder，而是更廣泛地針對 disruptive behavior，其範圍從頂嘴到嚴重的攻擊行為。Disruptive behavior 是幼兒最常見的心理健康問題，是幾種不同診斷的特徵，包括 oppositional defiant disorder (ODD)——極度的不服從和對權威人物的敵意——以及 conduct disorder，在這種 disorder 中，孩子們無視規則、打架、撒謊、偷竊並從事其他令人震驚的壞行為。
瑞恩患有 attention-deficit hyperactivity disorder (ADHD)，這通常會引發行為問題。他與其說是被 defiance 驅使，不如說是 inexorably 地被當下最吸引人的東西所吸引——電視節目、熱巧克力、遊樂場，甚至睡眠。他對追求當前活動的需要導致他拒絕 conflicting 的請求或 demands。每天早上，瑪麗亞都會強行把瑞恩從床上拉起來並給他穿衣服。當瑞恩的祖母放學後照顧他並關掉電視時，瑞恩生氣地把所有可用的書本和玩具扔到地板上。
超過 100 篇研究文章，包括八項 randomized trials，已經證明 PCIT 在改善此類反應方面非常有效，而且療效持久。利害關係超越了家庭 dynamics。有 significant behavior 問題的幼童 later on 有 serious antisocial behavior 的 high risk。“之前的研究非常清楚：如果 early child behavior 問題沒有得到糾正，它們很可能會 escalate 到更 destructive 和 intractable 的行為，” 疾病控制與預防中心的 developmental psychologist 詹妮弗·懷亞特·卡明斯基說。“Preventing 青少年的 risky 和 violent behavior 是一個重要的 public health issue。”
由於其 scientific backing，PCIT 正在獲得 international recognition，並在全國各地的診所中迅速取得進展——主要是在特拉華州、加利福尼亞州、卡羅來納州、賓夕法尼亞州、俄克拉荷馬州和愛荷華州——這些州正在實施 large-scale training programs。當 PCIT International（一個成立於 2009 年的組織）推出其 planned protocol 以 certifying therapists 時，這種療法很可能會得到更廣泛的 disseminated。Certification 將使 interested parents 能夠在 Internet 上找到 qualified therapists。
Recent adaptations 已經 retrofitted 了這種 approach，以 suit older children，並且——taking advantage of its emphasis on parenting skills——prevent relapse in abusive parents。PCIT 也為 controlling more moderate forms of troublesome behavior in children 提供了 useful tactics。“這是一種改變你的 vocabulary 並以 positive manner 與你的孩子交談的方式，” 特拉華州預防和行為健康服務部門的 clinical psychologist 約書亞·馬塞說。庫爾茨補充說，“這是應該給父母的手冊。”
“你的想象力像你的機器人一樣飛翔”
PCIT 起源於 1970 年代初期，當時 Sheila M. Eyberg 是俄勒岡健康科學大學的 clinical psychology intern。她用 play therapy 治療行為問題，在這種 therapy 中，therapist 指導孩子在 playtime 期間描述他或她的 emotions，以此作為 self-acceptance 的途徑。Eyberg 注意到她的 charges “似乎 calm down 了，‘self-correct’ 了，並試圖 please me，” 她在 2004 年的 PCIT Pages: The Parent-Child Interaction Therapy Newsletter 中寫道。但是，她寫道，“他們的 parents 沒有 reporting similar experiences at home。Nor were they reporting changes in their children's behaviors。” 孩子們沒有與他們的 parents bonding，而是與 Eyberg connecting。
Psychologist Constance Hanf，當時也在 O.H.S.U.，正在 piloting 一種 approach，旨在 address 這些 concerns。她正在 training mothers 充當她們 children 的 therapists，這些 children 有 developmental disabilities。Hanf 的 program 的 key target 是 parent-child bond。根據 attachment theory，這種 bond 提供了一個 secure base，孩子可以從中 explore the world，並幫助孩子 control 他或她的 emotions。在 Hanf 的 therapy 中，parents built 這種 connection，同時 playing 一個 child's choosing 的 game。作為 Hanf 的 students 之一，Eyberg constructed PCIT around her teacher's scaffold。
去年夏天，勞拉（化名）是一位 fun-loving young mother，在她的 therapy sessions 之一中 textbook demonstration 了 PCIT 的這個 element。她的兒子，我稱之為加布裡埃爾，一個 light brown、curly hair 的 small six-year-old，剛剛用 magnets 建立了一個 robot。
“哦，你選擇玩 magnets！” 勞拉說。“Beautiful robot。I love it。”
“現在它是一座 castle，” 加布裡埃爾談到他的 creation 時說。加布裡埃爾患有 ODD。
“It's so smart——你把 robot converted 成一座 castle，” 他的 mother 說。
加布裡埃爾伸出舌頭。“You're sticking out your tongue，” 勞拉敘述道。
“People hate him so he started to transform，” 加布裡埃爾談到他的 robot 時說。
“That's very smart，” 他的 mother compliments 道。“Thank you for telling me the whole story。” 加布裡埃爾開始用 funny、robotic voice 說話。勞拉模仿他。
“你的想象力像你的 robot 一樣飛翔，” 勞拉說。“You can come up with different designs like this。It's amazing to me。”
勞拉描述和 imitates 加布裡埃爾的行為，repeats 他說的話——所有這些都讓 child lead——並且 acts happy 和 relaxed。勞拉的 behavioral descriptions 也 show 她 is interested，demonstrate proper speech，並 help 加布裡埃爾 stay focused on the task。勞拉 frequently praises 這個男孩，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。勞拉已經 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，瑪麗亞和瑞恩剛剛開始的 phase，是 directed at limit setting 和 discipline。它也是 based on Hanf's therapy，其中 included 一個 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。
勞拉 close 了。加布裡埃爾 complies with some but not all of her requests。當勞拉說她想 do a puzzle 時，加布裡埃爾 protests：“I am tired of listening！I don't want to do this。Can we go out？” 加布裡埃爾 does not work on the puzzle for long，but he does eventually agree to sit next to 勞拉 and put the pieces away——and he never needs to sit in the time-out chair，although 勞拉 threatens to put him there。
加布裡埃爾和勞拉 have already come a long way。Earlier in the year，加布裡埃爾 had been very unhappy and angry。He acted aggressively toward 勞拉 and refused to obey her。“Get ready for bed or get ready for school……to get him to do anything was very，very hard，” 勞拉 recalls。Now 加布裡埃爾 complies with her requests much more often。“When I ask him to turn off the iPad，he hands it to me，” 勞拉 says。“He knows that if he doesn't，there's a consequence。”
在 1998 年 published 的 therapy 的 landmark test 中，Eyberg（現在在佛羅里達大學）和她的 colleagues 給 22 個有 ODD 的三到六歲 children 的 families 提供了 PCIT，並將其他 27 個 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（當時都在澳大利亞格里菲斯大學）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。
兒童保護
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（俄克拉荷馬大學健康科學中心的 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。
“請遞給我粉紅色的甜甜圈”
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。
回到兒童心理研究所，瑞恩已經 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。庫爾茨 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。瑪麗亞 remains calm。She smiles and laughs to help ease the tension。
Finally，瑞恩 elects to stay in the chair，so 瑪麗亞 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，瑪麗亞 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 庫爾茨 ends the session。
That afternoon 瑞恩 passed another milestone。When 庫爾茨 enters the room，瑪麗亞 flashes a wide smile。She gives 庫爾茨 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。