Cognitive therapy its goals and theory. Cognitive psychotherapy by Aaron Beck. supervisory workshop A.B. Kholmogorova and N.G. Garanyan

In his monograph “Cognitive Therapy and Emotional Disorder” (1976), A. Beck expresses a fundamentally new approach to the correction of emotional disorders, different from the traditional schools of psychoanalysis and behavioral therapy.

A cognitive approach to emotional disorders changes a person's view of himself and his problems. The client is taught the opportunity to see himself as an individual who is prone to giving rise to erroneous ideas, but also capable of abandoning erroneous ideas or correcting them. Only by identifying or correcting thinking errors can a client create a life of greater fulfillment for themselves.

The main idea of cognitive psychocorrection by A. Beck is that the decisive factor for the survival of the organism is the processing of information. As a result, behavioral programs are born. A person survives by receiving information from the environment, synthesizing it and planning actions based on this synthesis, i.e. developing your own behavior program.

The program can be normal (adequate) or inadequate. In the case of a cognitive shift in information processing, an anomalous program begins to form. For example, having gained certain experience in certain life situations, people begin to tendentiously interpret their experience: a person for whom the idea of a possible sudden death has special meaning (due to the fact that he has lost one of his close relatives) may, having experienced a threatening episode , begin to interpret normal bodily sensations as a signal of impending death. He develops anxiety

which can develop into painful-anxious behavior, while its behavior program is activated by the survival program. From the entire incoming flow of information, “danger signals” will be selected and “safety signals” will be blocked. And as a result, the client begins to react to relatively minor stimuli as if they were a strong threat, responding emotionally and behaviorally inappropriately.

Activated program for a cognitive shift in information processing. The normal program of correctly perceived and interpreted data is replaced by an “anxious program,” “depressive program,” “panic program,” etc. When this happens, the person begins to experience symptoms of anxiety, depression, or panic.

A. Beck believes that each person has his own weak point in cognitive functioning - “cognitive vulnerability.” It is this that predisposes a person to psychological stress.

Personality (according to A. Beck) is formed by schemas or cognitive structures, which represent basic beliefs. These schemas begin to form in childhood based on personal experiences and identification with significant others. Each person forms his own concept of himself, others, the world and the concept of his existence in the world. These concepts are reinforced by a person’s further experience and, in turn, influence the formation of other beliefs, values, and positions.

Schemas are stable cognitive structures that become active when exposed to specific stimuli, stress, or circumstances. Schemas can be either adaptive or dysfunctional. For example, the “cognitive triad of depression” includes:

Negative self-image (“I am maladjusted, worthless, a rejected loser”);

Negative view of the world (the client is convinced that the world makes excessive demands on him and erects insurmountable barriers to achieving goals and that there is no pleasure or satisfaction in the world);

Nihilistic view of the future (the client is convinced that the difficulties he is experiencing are insurmountable. Suicidal thoughts are born from a feeling of complete hopelessness).

Thus, emotional disturbances and behavioral disorders are viewed as mediated by cognitive structures and actual cognitive

processes (in which thought-cognition acts as intermediate variables).

Psychological disorders that precede the stage of neurophysiological disorders are associated with aberrations of thinking. (By aberration of thinking, A. Beck understood disturbances at the cognitive stage of information processing that distort the vision of an object or situation.) Distorted cognitions, i.e. Cognitive distortions cause false beliefs and self-signals and, as a result, inadequate emotional reactions.

Cognitive biases are systematic errors in judgment influenced by emotions. These include

1. Personalization - the tendency to interpret an event in terms of personal meanings. For example, people with increased anxiety believe that many events that are completely unrelated to them concern them personally or are directed against them personally. So, having met the frowning gaze of the hallway, the client thinks: “He feels disgusted with me. Everyone feels disgust when they see me.” Thus, the client overestimates both the frequency and the degree of negative feelings that he causes in other people.

2. Dichotomous thinking. A neurotic client tends to think in extremes in situations that touch his sensitive areas, such as self-esteem, with the possibility of being in danger. An event is designated only in black or white, only as good or bad, beautiful or terrible. This property is called dichotomous thinking. A person perceives the world only in contrasting colors, rejecting halftones and a neutral emotional state.

3. Selective abstraction (extraction). It is the conceptualization of situations based on details extracted from the context, while ignoring other information. For example, at a noisy party, a young man begins to be jealous of his girlfriend, who bowed her head to another person in order to hear him better.

4. Arbitrary conclusions - conclusions that are unsubstantiated or even contradict the obvious facts. For example, a working mother at the end of a hard day concludes: “I am a bad mother.”

5. Overgeneralization is an unjustified generalization based on a single case. For example, the client made a mistake, but thinks: “I always do everything wrong.” Or after an unsuccessful date, a woman concludes: “All men

98 are the same. They will always treat me badly. I will never succeed in relationships with men.”

6. Exaggeration (catastrophization) - exaggeration of the consequences of any events. For example, the client thinks: “If these people think badly of me, it will be simply terrible!”; “If I’m nervous during the exam, I’ll definitely fail and they’ll kick me out right away.”

99 Stages of cognitive correction work

1. Reduction of problems - identification of problems that have the same causes and their grouping. This applies to both symptoms (somatic, psychological, pathopsychological) and emotional problems themselves. In this case, strengthening of the targets of corrective action is achieved.

Another option for reducing problems is to identify the first link in the chain, which starts the entire chain of symbols.

2. Awareness and verbalization of maladaptive cognitions that distort the perception of reality.

A maladaptive cognition is any thought that evokes inappropriate or painful emotions and makes it difficult to solve a problem. Maladaptive cognitions are of the nature of “automatic thoughts”: they arise without any preliminary reasoning, reflexively. For the client, they are plausible, well-founded, and beyond doubt. “Automatic thoughts” are involuntary and do not attract the client’s attention, although they direct his actions.

To recognize maladaptive cognitions, the technique of “collecting automatic thoughts” is used.

The client is asked to focus on thoughts or images that cause discomfort in a problem situation (or similar to it). By focusing on automatic thoughts, the client can recognize them and record them. Usually, outside of a problem situation, these thoughts are difficult to recognize, for example, in people suffering from phobias. Their identification becomes easier when actually approaching such a situation. Repeated approach or immersion in a situation allows you to first realize, “collect” them, and then, instead of an abbreviated version (as in a telegram), present it in a more expanded form.

3. Distancing is a process of objective consideration of thoughts, in which the client views his maladaptive cognitions as psychological phenomena isolated from reality.

After the client has learned to identify his maladaptive cognitions, he needs to learn to look at them objectively, i.e. distance yourself from them.

Distancing increases the client's ability to differentiate between an opinion that needs to be justified (“I believe that ...”) and an irrefutable fact (“I know that ...”). Distancing develops the ability to differentiate between the external world and one’s relationship to it. By substantiating and proving the reality of his automatic thoughts by the client, the psychologist makes it easier for the client to distance himself from them and develops in him the skill of seeing hypotheses in them rather than facts. In the process of distancing, the way of distorting the perception of the event becomes clearer to the client.

4. Changing the rules governing the rules of conduct.

To regulate their lives and the behavior of other people, clients use rules (prescriptions, formulas). These systems of rules largely determine the designation, interpretation and evaluation of events. Those rules for regulating behavior that are absolute in nature entail regulation of behavior that does not take into account the real situation and therefore creates problems for the client.

In order for the client not to have such problems, he needs to modify them, make them less generalized, less personalized, more flexible, more taking into account reality.

The content of the rules for regulating behavior is centered around two main parameters: danger - safety and pain - pleasure. The danger-safety axis includes events associated with physical, psychological or psychosocial risk. A well-adapted person has a fairly flexible set of precise rules that allows him to relate them to the situation, interpret and assess the existing degree of risk. In situations of physical risk, the indicators of the latter can be sufficiently verified by one or more characteristics. In situations of psychological or psychosocial threat, verification of such indicators is difficult. For example, a person who is guided by the rule “It will be terrible if I am not up to par” experiences difficulties in communication due to an unclear definition of the concept

1 “to be on top,” and his assessment of the effectiveness of his interactions with his partner is associated with the same uncertainty. The client projects his assumptions about failure onto others’ perceptions of him.

All methods of changing rules related to the danger-safety axis come down to restoring the client’s contact with the avoided situation. Such contact can be restored by immersing oneself in the situation in the imagination, at the level of real action with a clear verbalization of new rules of regulation, allowing one to experience a moderate level of emotions.

Rules centered around the pain-pleasure axis lead to an exaggerated pursuit of certain goals to the detriment of others.

For example, a person who follows the rule “I will never be happy unless I am famous” condemns himself to ignoring other areas of his relationships in favor of slavishly following this rule. After identifying such positions, the psychologist helps the client realize the flawed nature of such rules, their self-destructive nature, and explains that the client would be happier and suffer less if he were guided by more realistic rules.

Classification of behavioral rules

Rules that formulate values that evoke certain stimuli that are subjectively perceived differently give rise to positive or negative emotions in customers (for example: “Unwashed vegetables are carcinogenic”).

2. Rules associated with the impact of the stimulus (for example: “After the divorce, everything will be different”).

3. Behavioral assessments (for example: “Because I stutter, no one listens to me”).

4. Rules related to the emotional and affective experience of the individual (for example: “At the mere memory of the exam, I get a shiver in my back,” “I have no more hope”).

5. Rules related to the impact of the reaction (for example: “I will be more punctual so as not to anger the boss”).

6. Rules associated with obligation and arising in the process of socialization of the individual (for example: “A person must receive a higher education in order to be happy”).

1 5. Change of attitude towards the rules of self-regulation.

6. Checking the truth of the rules, replacing them with new, more flexible ones. Initially, it is advisable to use productive problem solving skills

client in a non-problematic area, and then generalize these skills into an emotional-problem area.

Correction goals. The main goal is to correct inadequate cognitions, understand the rules of inadequate information processing and replace them with correct ones.

The tasks of a psychologist.

Teach the client to recognize connections between cognitive schemas, affect, and behavior. Learn to replace dysfunctional thoughts with more realistic interpretations.

Identify and change beliefs that predispose you to distort your experience.

Psychologist's position. Since A. Beck believes that the psychologist and the client are collaborators in the study of facts that support or refute the client’s cognitive schemes, this is a two-way process and it is a partnership. Therefore, a partnership must develop between the client and the psychologist. The client's interpretations or assumptions are considered by the psychologist as hypotheses that need to be tested and confirmed.

Requirements and expectations from the client. The client is expected to accept the basic assumption of cognitive theory about the dependence of emotions on thinking. Establishing a partnership relationship with a psychologist requires high activity, responsibility, and the absence of “psychological dependency” from the client. Blind faith in the psychologist and increased skepticism of the client are two poles of a negative attitude towards the upcoming interaction. For the success of corrective influences, it is necessary to bring such positions to the center before starting activities.

102 Techniques

1. “Socratic dialogue.” Conversation is the main therapeutic tool in cognitive psychocorrection. The psychologist carefully designs questions to ensure new learning. The purpose of asking these questions is as follows:

Clarify or identify client problems;

1. help the client identify thoughts, images, assumptions;

Study the meaning of events for the client;

Assess the consequences of maintaining maladaptive thoughts and behaviors.

Based on the answers to the constructed questions, the client comes to certain logical conclusions. Questions are posed in such a way as to lead him to the inevitable conclusion without the client resorting to psychological defenses. That is, so that the client can look at his assumptions from a different point of view in such a way that psychological defenses do not interfere with the awareness of this different position.

2. “Filling the void.” The method is used when the level of emotions experienced is moderate and the cognitions accompanying them are unclear and insufficiently formalized.

To identify the patient’s unconscious thoughts, the client is asked to fill out the following sequence: A > B > C.

A > - some event.

C > is the client’s emotional reaction to the event.

B > - the client’s thoughts connecting these two events.

The client is taught to observe the sequence of external events (A) and reactions to them (C). The client needs to fill the void in his consciousness (B), which is the connecting link between Li S. B are thoughts or images that arose during this period and make the connection between A and C clear.

For example, seeing an old acquaintance on the street, the client felt sadness and sadness. A - meeting with a person; S - sadness; B is a cognition that links these two events. The client further explains: “When I saw this person, I thought that maybe he wouldn’t recognize me or would say that I looked bad or would be rude and would upset me. After that there was a feeling of sadness.” After the connection between an event and an emotional reaction has been revealed by the client, the psychologist can, based on the data obtained, put forward a hypothesis and present it to the client for discussion (confirmation).

The client has the right to agree or disagree with the psychologist and find more precise formulations of his beliefs. Once a belief is identified, it is open to modification. Belief modification is carried out in the following ways:

1. the psychologist can ask the client whether the belief is reasonable;

May ask the client to give reasons for and against maintaining this belief;

The psychologist may ask the client to provide evidence, facts that contradict this belief (i.e., refute it).

3. Decatastrophization ("what... if" technique). The technique is designed to explore actual factual events and consequences that, in the client's mind, cause him psychological harm and cause feelings of anxiety. This technique helps clients cope with the aftermath of a fearful event.

In a conversation with a psychologist, a situation is considered that frightens the client and is perceived by him as catastrophic. The psychologist asks the client the question: “What will happen if this situation occurs?” The client lists the possible consequences of this situation. The psychologist repeats the question: “What will happen if...?” When considering all the consequences of the situation, the client comes to the conclusion that the situation is not as significant as it seemed to him at the very beginning of the conversation.

4. Cognitive reattribution. The technique is a sequence of actions with the goal of changing the automated (skills) “chains of thoughts” that pathologize the client and is aimed at verifying the correctness of the client’s beliefs. The psychologist and client consider alternative causes of events. The reattribution technique involves checking reality and examining all the facts that influenced the occurrence of the situation. It includes the following techniques:

1. Checking the completeness of the client’s cognitions with real content. There is a transition to a more meaningful and multifaceted understanding of the object of the client’s pathologizing chain of judgments (one’s “I”, field of activity, relationship with another person, etc.).

2. Revealing the inconsistency of the client’s ideas about the causes of the chain of judgments that pathologizes him. The object of influence at this stage is sound judgments with which the client habitually substantiates his feelings of guilt, anxiety, inferiority, and manifestations of aggressiveness.

3. Consolidation of new attributions (in discussion, role-play, in everyday life).

104 In correctional practice, the technique is used for depressive neuroses, reactive depression, phobias, hysterical reactions, addictions (drugs, alcohol). Contraindicated for use in psychotic disorders.

5. Reframing. A technique designed to mobilize a person who feels that a problem is out of their control. The client is invited to formulate the problem in a new way, so that it receives a concrete and specific sound. For example, a person who believes: “Nobody pays attention to me” is asked to reformulate the problem: “I need emotional warmth. I don't receive it. So I need to reach out to other people so that they can take care of me.”

6. Decentralization. A method of freeing the client from the ability to see himself as the point of concentration of all events. To test the client's distorted beliefs, he is asked to conduct behavioral experiments.

For example, one client believed that during a meeting everyone was watching him and noticed his uncertainty, so he preferred to remain silent and not speak out. Because of this, he had problems with management. The client was encouraged to observe those around him instead of focusing on his discomfort. When he observed the employees, he saw that some people were listening to the speaker, others were writing something, and others were dreaming. He came to the conclusion that others were concerned with their own affairs and not with their attitude toward him. And his attitude towards himself changed.

7. Hypothesis testing. A client who is in an emotionally unstable state has his own hypothesis that explains his condition. The psychologist asks

provide specific facts that explain this hypothesis. In this case, one should not use generalizing labels, unclear terms and vague concepts.

For example, a client claims that he is a bad teacher. The psychologist asks to provide facts and arguments in favor of such a conclusion. When considering these arguments, it may become clear that some aspects of the activity are not taken into account. After this, the client is asked to provide feedback facts: the opinions of parents, judgments, reviews of students, work colleagues, which the client himself must obtain. After considering all the facts together, the client comes to the conclusion that in fact he is not as bad as he thought and his opinion about himself is wrong.

1 8. Planning activities. This procedure boils down to the fact that the client is asked to create a daily routine, outline a plan for one or another activity, and rate the degree of satisfaction from this activity using a scale from 0 to 10 points. Filling out such daily routines and then reviewing them with a psychologist leads to the client becoming convinced that he is able to control his behavior. And his emotional assessment of this activity depends on a number of factors, which leads to a change in his emotional attitude towards himself and the activity in which he is engaged.

For example, those clients who believe that they are constantly in a state of anxiety, seeing their assessment of different types of activities, are convinced that the intensity of emotional stress varies depending on the time of day or the job performed and that in fact their feelings are not so deep , as they imagined before filling out this schedule.

Aaron Temkin Beck (1921 - present) was born in Providence in the USA into a Jewish family that emigrated in 1906 from western Ukraine.

Three years before the birth of their son, his parents lost their daughter, who died of the flu, and Aaron's mother never recovered from this loss. This led to the fact that the boy was brought up and grew up in an atmosphere of hopelessness and constant depression in which his mother was. Perhaps it is for this reason that, after graduating from school, he entered the Department of Psychiatry at the University of Pennsylvania.

After graduating from university, Beck begins his own practice, but for quite a long time he works within the framework of the psychoanalytic concept in which he was educated. However, over time, he became disillusioned with psychoanalysis and the young scientist began to look for his own path, which led him to a theory that was very original for that time, explaining the origin of psychological problems.

In psychoanalysis, the main cause of an individual’s neurotic manifestations is considered to be factors of the unconscious, which, entering into an obvious or hidden contradiction with the super ego, give rise to neurotic manifestations. The solution to the problem within the framework of this school is seen as the therapeutic method of psychoanalysis, which consists in the patient’s awareness of his unconscious manifestations and the direct connection of neurosis with traumatic experiences. The key to successful psychoanalysis is the subsequent reassessment of an event that was initially traumatic for the individual and a reduction in its significance for the latter.

Within the framework of behaviorism (another psychological paradigm that has gained particular popularity in the USA), the cause of neurotic manifestations was considered to be the patient’s maladaptive behavior, which was developed gradually as a result of repeated influences (stimuli). The influences (stimuli) that gave rise to such behavioral strategies lay in the patient's past, but behavior therapy did not emphasize the importance of memories, as it did in psychoanalysis. As part of the practical application of behavioral psychology, it was believed that a sufficient solution to psychological problems was the use of special teaching techniques, which were used to change the patient’s behavior, that is, to change a maladaptive strategy to an adaptive one. Behaviorists believed that developing correct behavior was the key to success.

As for Aaron Beck, his new concept lay outside the scope of the mentioned methods and was very original for that time.

Theoretical basis of cognitive therapy.

Beck considered the cause of patients' problems in the way in which they interpreted the events of the world around them. The scheme he proposed for human reaction to these events was as follows.

External event => cognitive system => mental interpretation (idea about what happened) => reaction to the event (feelings and (or) behavior).

If we now remember the basic principles of behaviorism, then there, human consciousness was considered as a black box about which no conclusions should be drawn, because what is happening inside cannot be detected in an objective scientific way.

This was both a great advantage of the behavioral approach, since it transferred psychology into the category of a scientific discipline, and a great disadvantage, since it excluded stimulus => response such an obviously important component of the process as consciousness and what happened in it from the point of view of the individual (albeit subjective).

As for psychoanalysis, which was dominant at that time in Europe, the situation was exactly the opposite. This teaching took into account what was happening in the patient’s field of consciousness, based only on Freud’s scientific assumption about the structure of this consciousness, and even undertook to interpret the cause-and-effect relationships of these essentially virtual processes. The patient’s behavior itself was determined by his neurotic tendencies, which lay in his past history.

Aaron Beck was one of the first who complicated (expanded) the human behavioral scheme and introduced consciousness into it as a cognitive component of the process stimulus => response, thus essentially improving the behavioral approach. Also, he approached human consciousness in a completely different way than in psychoanalysis (and much simpler), reducing it to purely cognitive processes and their results.

Even more important was the fact that Beck’s theory, due to its simplicity, made it possible to easily transfer it into the field of practical psychology and make it an instrument of psychological help to people.

Principles of cognitive psychology.

Let's consider the basic principles of his approach. So, according to Aaron Beck, the source of a person’s reactions to surrounding events was his ideas about the world around him, which were formed earlier and represent not only ideas about the external world, but also the inner world, in other words, the individual’s ideas about himself. Here is a quote from him that quite clearly illustrates his approach.

“A person’s thoughts determine his emotions, his emotions determine his behavior, and his behavior in turn determines our place in the world around us.” “It’s not that the world is bad, but how often we see it that way.” — A. Beck.

However, if we have clear ideas about the world, then their discrepancies with reality will inevitably lead to a negative psychological reaction (frustration), and in the case of strong discrepancies, to serious psychological problems.

Aaron Beck, as a psychologist, worked quite a lot with patients suffering from depression and in the process of such observations he deduced their main emotional manifestations, which were often dominated by the theme of hopelessness, guilt, and loss.

Based on the experience of studying such patients, Beck suggested that neurotic manifestations appeared largely due to the perception of the world in negative colors, that is, the cognitive system of his patients was initially tuned to this type of reaction. According to Beck, the neurotic manifestations of such people had three features.

- Regardless of what is happening, a person mainly highlights the negative aspects of external events, belittling the importance of the positive side or even not noticing it at all.

— Due to the peculiarities of this perception of events in the outside world, these people are also characterized by a pessimistic view of the future, which, in their opinion, cannot bring them anything positive, because the expected events also do not bring anything good.

— Many of these people are characterized by low self-esteem, that is, a person initially views himself as unworthy, failed, and hopeless.

In addition, all of the above often leads to purely cognitive distortions, when a person bases his behavior on erroneous generalizations. An example of such generalizations is cognitive assumptions - “nobody needs me,” “I’m good for nothing,” “the world is unfair,” etc.

Of course, the human cognitive system is not formed suddenly and not out of nowhere; it happens gradually and as a result of the influence of well-defined external events.

When such events occur constantly and are of a negative nature, which often happens during the period of an individual’s growth and maturation, they often talk about the formation of persistent behavioral strategies that quickly become automatic in nature and, being quite adaptive during the period of their appearance, become completely destructive when other conditions and circumstances, for example already in adulthood. But in reality, due to the life circumstances mentioned above, it is the person’s cognitive system that is first formed, which determines his behavior.

According to Aaron Beck, the human cognitive system is created mainly during childhood. At the same time, children, in this early period of life, think in polar categories of the all-or-nothing type, often this way of thinking is called black-and-white thinking, and under certain circumstances, this type of thinking persists into adulthood, which leads to maladaptive behavior, erroneous perception of the world and subsequent psychological problems.

Of course, people's tendencies toward erroneous thinking, generalizations, and stereotypical perceptions of the world are not always the cause of neurotic symptoms, much less depression. A huge number of people (if not the vast majority) have a cognitive system (a map of the mind) that is largely built on erroneous assumptions, yet most people can hardly be called neurotic. This means that the causes of serious psychological problems such as depression are of course not limited to simple thinking.

Aaron Beck's therapeutic method.

This type of therapy is a logical continuation of the founder’s ideas, and their transfer from the field of scientific assumptions to the category of practical psychology, or otherwise, a method of psychological assistance.

This is a systematic approach based on the practical task of solving specific client problems. The appeal of the method specifically to the conscious processes of the individual does not mean at all that Beck completely ignored psychoanalytic techniques. In addition, behavioral techniques were actively used in the system, which ultimately led to the development of a combined method of cognitive-behavioral psychotherapy.

Working with a client within the framework of cognitive psychotherapy.

First of all, the psychologist, together with the client, determines the range of problems on which they will work, after which the practical task of this work is set - solving a specific problem. This specificity is very important for forming the client’s intention and readiness for routine therapy. A number of requirements are put forward to the therapist, essentially these are principles taken from humanistic psychology - empathy, naturalness, integrity, acceptance of the client in an unconditionally positive way.

4. Decastrophization. With depression, anxiety disorders, and simply cognitive distortions, many people tend to view events that are not consistent with their expectations as a disaster. At the same time, this can be either the loss of a job or a cup of tea being knocked over on a clean tablecloth. With such symptoms, the therapist suggests considering the possible real consequences of the “catastrophe”, which most often turn out to be only temporary difficulties, but not the end of the world.

5. Teaching the desired behavior. Through repeated repetition of the desired behavior, the client develops an adaptive behavioral strategy. For example, a timid client is given the task of gradually expanding his ability to communicate in society.

We have listed the basic principles of cognitive therapy and mentioned several common ways of working with a client. Of course, there are many more ways that a cognitive psychotherapist can, in principle, use in his work.

From what has been written above, it is easy to understand that cognitive therapy is not at all limited to purely cognitive techniques when working with a client. As we have seen, behavioral methods are most actively used, but besides them, they can also be psychoanalysis and humanistic principles, which organically complement Beck’s technique.

Today, cognitive behavioral psychotherapy is one of the most popular methods in practical psychology, and Aaron Beck can rightfully be considered one of its founding fathers. An interesting fact is that, practically parallel in time and independently of each other, Aaron Beck and Albert Ellis created largely similar psychotherapeutic techniques.

In the case of Albert Ellis, this is rational-emotive therapy, which is based on similar ideas. However, their practical application is also similar.

Cognitive therapy

Basic concept

Cognitive therapy was created by Aaron Beck in the 1960s. In the preface to the famous monograph “Cognitive Therapy and Emotional Disorders,” Beck declares his approach as fundamentally new, different from the leading schools devoted to the study and treatment of emotional disorders - traditional psychiatry, psychoanalysis and behavioral therapy. These schools, despite significant differences, share a common fundamental assumption: the patient is tormented by hidden forces over which he has no control. Traditional psychiatry looks for biological causes, such as biochemical and neurological abnormalities, and uses drugs and other means to reduce emotional distress.

Psychoanalysis explains neurosis by subconscious psychological factors: subconscious elements are covered with psychological veils, which can only be penetrated with the help of psychoanalytic interpretations. Behavioral therapy views emotional disturbance in terms of random conditioned responses that occurred earlier in the patient's life. According to behaviorist theory, to eliminate these conditioned reflexes, the patient’s mere knowledge of them or his desire is not enough - the development of “conditioned counter-reflexes” under the guidance of a competent behavioral therapist is required.

So, representatives of these three leading schools argue that the source of the patient's disorder is outside his consciousness. They pay little attention to conscious concepts, concrete thoughts and fantasies, that is, cognition. A new approach, cognitive therapy, believes that emotional disorders can be approached in a completely different way: the key to understanding and solving psychological problems lies in the minds of patients.

Cognitive therapy assumes that the patient's problems stem mainly from certain distortions of reality based on erroneous premises and assumptions. These misconceptions arise as a result of incorrect learning during the process of cognitive, or cognitive, personality development. From this it is easy to derive the treatment formula: the therapist helps the patient to find distortions in thinking and learn alternative, more realistic ways of perceiving his experience.

The cognitive approach to emotional disorders changes a person's attitude towards himself and his problems. By abandoning the idea of oneself as a helpless product of biochemical reactions, blind impulses or automatic reflexes, a person gets the opportunity to see in himself a being prone to giving rise to erroneous ideas, but also capable unlearn from them or correct them. Only by identifying and correcting the errors of thinking can he create for himself a life with a higher level of self-fulfillment.

The main concept of cognitive therapy is that the decisive factor for the survival of the organism is the processing of information. We could not survive if we did not have a functional apparatus for receiving information from the environment, synthesizing it, and planning actions based on this synthesis.

In various psychopathological conditions (anxiety, depression, mania, paranoid state, obsessive-compulsive neurosis, etc.), information processing is influenced by systematic bias. This bias is specific to various psychopathological disorders. In other words, patients' thinking is biased. Thus, a depressed patient selectively synthesizes themes of loss or defeat from information provided by the environment. And in an anxious patient there is a shift towards themes of danger.

These cognitive shifts are facilitated by specific attitudes that position people in certain life situations to interpret their experiences in a biased way. For example, a person for whom the idea of sudden death is particularly salient may, after experiencing a life-threatening episode, begin to interpret normal bodily sensations as signals of impending death, and then develop anxiety attacks.

A cognitive shift can be analogously thought of as a computer program. Each disorder has its own specific program. The program dictates the type of input information, determines the method of processing information and the resulting behavior. In anxiety disorders, for example, a “survival program” is activated: the individual selects “danger signals” from the flow of information and blocks “safety signals.” The resulting behavior will be that he will overreact to relatively minor stimuli as a strong threat and will respond with avoidance.

The activated program is responsible for cognitive shift in information processing. The normal program of correctly selected and interpreted data is replaced by an "anxious program", a "depressive program", a "panic program", etc. When this happens, the individual experiences symptoms of anxiety, depression or panic.

Cognitive therapy strategies and techniques are designed to deactivate such maladaptive programs, to shift the information processing apparatus (cognitive apparatus) to a more neutral position.

Each person has his own weak point in cognitive functioning - “cognitive vulnerability”, which predisposes him to psychological stress. These “vulnerabilities” relate to the structure of the personality.

Personality is formed diagrams, or cognitive structures that represent basic beliefs (attitudes). These schemas begin to form in childhood based on personal experiences and identification with significant others. People form concepts about themselves, others, and how the world works. These concepts are reinforced by further learning experiences and, in turn, influence the formation of other beliefs, values and attitudes.

Schemas can be adaptive or dysfunctional. Schemas are stable cognitive structures that become active when triggered by specific stimuli, stressors, or circumstances.

Patients with borderline personality disorders have so-called early negative schemas, early negative core beliefs. For example, “something wrong is happening to me,” “people should support me and should not criticize, disagree with me, or misunderstand me.” With such beliefs, these people easily experience emotional disturbances.

Another common belief was called the "conditional assumption" by Beck. Such assumptions, or positions, begin with “if.” Two conditional assumptions often noted in patients prone to depression are: “If I don’t succeed in everything I do, no one will respect me”; “If a person doesn’t love me, then I’m not worthy of love.” Such people can function relatively well until they experience defeat or rejection. After this, they begin to believe that no one respects them or that they are unworthy of love. In most cases, such beliefs can be dispelled in short-term therapy, but if they form the core of the beliefs, longer-term treatment is required.
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Cognitive models of emotional and personality disorders

Cognitive model of depression. A. Beck describes the cognitive triad in depression.

1. Negative self-image. A depressed individual perceives himself as maladjusted, worthless, and rejected.

2. Negative view of the world. A depressed individual is convinced that the world makes excessive demands on a person and erects insurmountable barriers to achieving goals. The world is devoid of pleasure and satisfaction.

3. Nihilistic view of the future. A depressed individual is convinced that the difficulties he is experiencing are insurmountable. This hopelessness often leads him to suicidal thoughts.

^ A cognitive model of anxiety disorders. The anxious patient's thinking is dominated by themes of danger, that is, he envisions events that will be detrimental to him, his family, his property, and other values.

The anxious patient's perception of danger is based on false assumptions or is excessive, whereas the normal response is based on a more accurate assessment of the risk and extent of the danger. Additionally, normal individuals can control their misperceptions using logic and evidence. Anxious individuals have difficulty recognizing safety cues and other cues that reduce the threat of danger. Thus, in cases of anxiety, cognitive content revolves around the theme of danger and the individual tends to exaggerate the likelihood of harm and reduce his ability to cope.

Mania. The prejudicial thinking of a manic patient is the opposite of a depressive patient. Such individuals selectively perceive the benefits of all life experiences, blocking negative experiences or interpreting them as positive and unrealistically expecting favorable results. Exaggeration of abilities, merits and achievements leads to a feeling of euphoria. The constant stimulation coming from inflated self-esteem and overly optimistic expectations provides enormous sources of energy and engages the manic individual in constant activity aimed at achieving the goal.

^ Cognitive model of panic disorder. Patients with panic disorder tend to view any unexplained symptom or sensation as a sign of imminent disaster. The main feature of people with panic reactions is the belief that their vital systems - cardiovascular, respiratory, central nervous - will collapse. Because of their fear, they constantly listen to internal sensations and therefore notice and exaggerate sensations that go unnoticed in other people.

Patients with panic disorders have specific cognitive deficit: they are unable to perceive their sensations realistically and interpret them catastrophically.

Patients who have had one or more panic attacks in a particular situation begin to avoid those situations. Anticipation of such an attack triggers a variety of autonomic symptoms, which are then incorrectly interpreted as signs of imminent misfortune (heart attack, loss of consciousness, suffocation), which can lead to a full-blown panic attack. Patients with panic disorder often develop agoraphobia. They end up not leaving their home or limit their activities so much that they cannot go far from home and need to be accompanied.

^ Cognitive model of phobia. With phobias, there is a premonition of physical or psychological harm in specific situations. If the patient is able to avoid such a situation, he will not feel threatened and will remain calm. If he finds himself in such a situation, he will feel subjective and physiological symptoms of anxiety.

Fear of particular situations is based on the patient's exaggerated idea of the special harmful properties of these situations. Thus, a patient with a phobia of tunnels experiences fear of a crash in a tunnel and his own death from suffocation; another patient will be terrified by the possibility of an acute, fatal illness if he is not helped in time.

At evaluation phobias there is a fear of failure in social situations, in an exam, or in public speaking. Behavioral and physiological reactions to potential "danger" (rejection, undervaluation, failure) can interfere with the patient's functioning to such an extent that they can cause exactly what the patient fears.

^ Cognitive model of paranoid states. A paranoid individual attributes prejudicial attitudes toward himself to other people. Other people deliberately insult, interfere, criticize. Unlike depressed patients, who believe that perceived insults or rejection are fair, paranoid patients believe that others are treating them unfairly.

Unlike depressed patients, paranoid patients do not have low self-esteem. They are more concerned with the injustice of perceived attacks and invasions than with actual losses.

^ Cognitive model of obsessions and compulsions. Patients with obsessions question situations that most people consider safe. Doubt usually concerns situations that are potentially dangerous.

Obsessive patients constantly doubt whether they have performed an action necessary for safety (for example, whether they turned off the gas stove, whether they locked the door at night; they may be afraid of germs). No amount of dissuasion eliminates fear.

Their main feature is a sense of responsibility and the belief that they are responsible for committing an action that could harm them and their loved ones.

Compulsive patients attempt to reduce excessive doubts by performing rituals designed to neutralize and prevent unhappiness. Compulsive hand washing, for example, is based on the patient's belief that he has not removed all dirt from his body.

^ Cognitive model of hysteria. In hysteria, the patient is convinced that he has a somatic disorder. Since the imagined disorder is not fatal, he tends to accept it without much anxiety. Patients suffering from a phobia are essentially “sensory fantasists,” that is, they imagine an illness and then experience a sensory sensation as evidence confirming the presence of that illness. The patient usually experiences sensory or motor abnormalities that correspond to his erroneous belief in organic pathology.

^ Cognitive model of anorexia nervosa. Anorexia nervosa and bulimia represent constellations of maladaptive beliefs that revolve around one central assumption: “The weight and shape of my body determines my worth and my social acceptability.” Beliefs that revolve around this assumption include, for example, “I will be ugly if I weigh more,” “The only thing in my life that I can control is my weight,” and “If I don’t starve, I will gain weight—” and this is a disaster!

Patients with anorexia nervosa exhibit typical distortions in information processing. They misinterpret symptoms of stomach fullness after eating as signs that they are gaining weight. In addition, they incorrectly perceive their image in the mirror or in a photograph as more voluminous than it actually is.

^ A cognitive model of personality disorders. Disturbed personality is based on genetic predisposition and learning experiences. Each personality disorder is characterized by a core belief and a corresponding behavioral strategy (A. Beck and colleagues). A description of basic beliefs (schemas) and behavioral strategies for various types of personality disorders is given in Table. 8.1.

In every personality disorder, both overdeveloped and underdeveloped strategies can be found. For example, in paranoid disorder, distrust is an overdeveloped strategy, and trust is an underdeveloped strategy. The dysfunctional schemas that characterize personality disorders are extremely persistent, so cognitive restructuring takes longer in these patients and involves a more in-depth exploration of the origins of the schemas than in patients with emotional disturbances.

Table 8.1. Basic beliefs and corresponding behavioral strategies for various types of personality disorders

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Cognitive psychotherapy is a form of structured, short-term, directive, symptom-oriented strategy for stimulating transformations in the cognitive structure of the personal “I” with evidence of transformations at the behavioral level. This direction generally refers to one of the concepts of modern cognitive-behavioral teaching in psychotherapeutic practice.

Cognitive-behavioral psychotherapy studies the mechanisms of an individual’s perception of circumstances and the individual’s thinking, and contributes to the development of a more realistic view of what is happening. Due to the formation of an adequate attitude towards occurring events, more consistent behavior arises. Cognitive psychotherapy, on the other hand, aims to help individuals find solutions to problematic situations. It works in circumstances where there is a need to find new forms of behavior, build the future, and consolidate the result.

Cognitive psychotherapy techniques are constantly used at certain phases of the psychotherapeutic process in combination with other techniques. The cognitive approach to defects in the emotional sphere transforms the point of view of individuals on their own personality and problems. This type of therapy is convenient because it can be seamlessly combined with any psychotherapeutic approach and can complement other methods and significantly enhance their effectiveness.

Beck's cognitive psychotherapy

Modern cognitive-behavioral psychotherapy is considered a general name for psychotherapies, the basis of which is the assertion that the factor provoking all psychological deviations are dysfunctional views and attitudes. Aaron Beck is considered the creator of the field of cognitive psychotherapy. He gave rise to the development of the cognitive direction in psychiatry and psychology. Its essence lies in the fact that absolutely all human problems are formed by negative thinking. A person interprets external events according to the following scheme: stimuli influence the cognitive system, which, in turn, interprets the message, that is, thoughts are born that give rise to feelings or provoke certain behavior.

Aaron Beck believed that people's thoughts determine their emotions, which determine the corresponding behavioral reactions, and those, in turn, shape their place in society. He argued that it is not the world that is inherently bad, but people see it that way. When an individual's interpretations diverge greatly from external events, mental pathology appears.

Beck observed patients suffering from neurotic. During his observations, he noticed that the themes of defeatism, hopelessness and inadequacy were constantly heard in the experiences of patients. As a result, I came up with the following thesis that a depressive state develops in subjects who perceive the world through three negative categories:

A negative view of the present, that is, regardless of what is happening, a depressed person concentrates on negative aspects, despite the fact that everyday life gives them certain experiences that most individuals enjoy;

Hopelessness felt about the future, that is, a depressed individual, imagining the future, finds exclusively gloomy events in it;

Low self-esteem, that is, the depressed subject thinks that he is an insolvent, worthless and helpless person.

Aaron Beck in cognitive psychotherapy developed a behavioral therapeutic program that uses mechanisms such as modeling, homework, role-playing games, etc. He mainly worked with patients suffering from various personality disorders.

His concept is described in a work entitled: “Beck, Freeman, cognitive psychotherapy for personality disorders.” Freeman and Beck were convinced that each personality disorder is characterized by the predominance of certain views and strategies that form a specific profile characteristic of a particular disorder. Beck argued that strategies can either compensate for or stem from certain experiences. Deep patterns of correction of personality disorders can be deduced as a result of a quick analysis of an individual’s automatic thoughts. The use of imagination and re-experiencing traumatic experiences can trigger the activation of deep circuits.

Also in the work of Beck and Freeman, “Cognitive Psychotherapy of Personality Disorders,” the authors focused on the importance of psychotherapeutic relationships in working with individuals suffering from personality disorders. Because quite often in practice there is such a specific aspect of the relationship built between the therapist and the patient, known as “resistance”.

Cognitive psychotherapy for personality disorders is a systematically designed, problem-solving direction of modern psychotherapeutic practice. It is often limited in time and almost never exceeds thirty sessions. Beck believed that a psychotherapist should be benevolent, empathetic and sincere. The therapist himself must be the standard of what he seeks to teach.

The ultimate goal of cognitive psychotherapy is to identify dysfunctional judgments that trigger depressive attitudes and behavior, and then transform them. It should be noted that A. Beck was not interested in what the patient thinks about, but how he thinks. He believed that the problem is not whether a given patient loves himself, but what categories he thinks in depending on the conditions (“I am good or bad”).

Methods of cognitive psychotherapy

The methods of cognitive psychotherapy include the fight against negative thoughts, alternative strategies for perceiving the problem, secondary experience of situations from childhood, and imagination. These methods are aimed at creating opportunities for forgetting or new learning. In practice, it was revealed that cognitive transformation depends on the degree of emotional experience.

Cognitive psychotherapy for personality disorders involves the use in combination of both cognitive methods and behavioral techniques that complement each other. The main mechanism for a positive result is the development of new schemes and the transformation of old ones.

Cognitive psychotherapy, used in its generally accepted form, counteracts the individual’s desire for a negative interpretation of events and themselves, which is especially effective for depressive moods. Since depressed patients are often characterized by the presence of thoughts of a certain type of negative orientation. Identifying such thoughts and defeating them is of fundamental importance. For example, a depressed patient, recalling the events of last week, says that then he could still laugh, but today it has become impossible. A psychotherapist practicing a cognitive approach, instead of accepting such thoughts unquestioningly, encourages studying and challenging the course of such thoughts, asking the patient to remember situations when he overcame a depressive mood and felt great.

Cognitive psychotherapy is aimed at working with what the patient tells himself. The main psychotherapeutic step is the patient's recognition of certain thoughts, as a result of which it becomes possible to stop and modify such thoughts before their results lead the individual very far. It becomes possible to change negative thoughts to others that can obviously have a positive effect.

In addition to counteracting negative thoughts, alternative coping strategies also have the potential to transform the quality of the experience. For example, the general feeling of a situation is transformed if the subject begins to perceive it as a challenge. Also, instead of desperately trying to succeed by performing actions that the individual is not able to do well enough, one should set oneself as the immediate goal of practice, as a result of which one can achieve much greater success.

Cognitive psychotherapists use the concepts of challenge and practice to confront certain unconscious assumptions. Recognizing the fact that the subject is an ordinary person with inherent flaws can minimize the difficulties created by an attitude of absolute striving for perfection.

Specific methods for detecting automatic thoughts include: writing down similar thoughts, empirical testing, reappraisal techniques, decentering, self-expression, decatastrophizing, targeted repetition, use of imagination.

Cognitive psychotherapy exercises combine activities to explore automatic thoughts, analyze them (which conditions provoke anxiety or negativity) and perform tasks in places or conditions that provoke anxiety. Such exercises help reinforce new skills and gradually modify behavior.

Cognitive psychotherapy techniques

The cognitive approach to therapy is inextricably linked with the formation of cognitive psychology, which places the main emphasis on the cognitive structures of the psyche and deals with personal elements and logical abilities. Cognitive psychotherapy training is widespread today. According to A. Bondarenko, the cognitive direction combines three approaches: direct cognitive psychotherapy by A. Beck, the rational-emotive concept of A. Ellis, and the realistic concept of V. Glasser.

The cognitive approach involves structured learning, experimentation, mental and behavioral training. It is designed to assist the individual in mastering the operations described below:

Discovering your own negative automatic thoughts;

Finding connections between behavior, knowledge and affects;

Finding facts “for” and “against” identified automatic thoughts;

Finding more realistic interpretations for them;

Learning to identify and transform disorganizing beliefs that lead to disfigurement of skills and experiences.

Training in cognitive psychotherapy, its basic methods and techniques helps to identify, dismantle and, if necessary, transform negative perceptions of situations or circumstances. People often begin to fear what they have prophesied for themselves, as a result of which they expect the worst. In other words, the individual’s subconscious warns him of possible danger before he gets into a dangerous situation. As a result, the subject becomes afraid in advance and tries to avoid it.

By systematically monitoring your own emotions and trying to transform negative thinking, you can reduce premature thinking, which can be modified into a panic attack. With the help of cognitive techniques, it is possible to change the fatal perception characteristic of such thoughts. Thanks to this, the duration of a panic attack is shortened and its negative impact on the emotional state is reduced.

The technique of cognitive psychotherapy consists of identifying the attitudes of patients (that is, their negative attitudes should become obvious to patients) and helping them to understand the destructive impact of such attitudes. It is also important that the subject, based on his own experience, make sure that, due to his own beliefs, he is not happy enough and that he could be happier if he were guided by more realistic attitudes. The role of the psychotherapist is to provide the patient with alternative attitudes or rules.

Cognitive psychotherapy exercises for relaxation, stopping the flow of thoughts, and controlling impulses are used in conjunction with the analysis and regulation of daily activities in order to increase the subjects’ skills and focus on positive memories.

Cognitive therapy

Basic concept

So, representatives of these three leading schools argue that the source of the patient's disorder is outside his consciousness. They pay little attention to conscious concepts, concrete thoughts and fantasies, that is, cognitions. A new approach, cognitive therapy, believes that emotional disorders can be approached in a completely different way: the key to understanding and solving psychological problems lies in the minds of patients.

The cognitive approach to emotional disorders changes a person's attitude towards himself and his problems. By abandoning the idea of oneself as a helpless product of biochemical reactions, blind impulses or automatic reflexes, a person gains the opportunity to see in himself a being prone to giving birth to erroneous ideas, but also capable of unlearning them or correcting them. Only by identifying and correcting the errors of thinking can he create for himself a life with a higher level of self-fulfillment.

In various psychopathological conditions (anxiety, depression, mania, paranoid state, obsessive-compulsive neurosis, etc.), information processing is influenced by systematic bias. This bias is specific to various psychopathological disorders. In other words, patients' thinking is biased. Thus, a depressed patient selectively synthesizes themes of loss or defeat from information provided by the environment. And in an anxious patient there is a shift towards themes of danger.

The activated program is responsible for cognitive shift in information processing. The normal program of correctly selected and interpreted data is replaced by an "anxious program", a "depressive program", a "panic program", etc. When this happens, the individual experiences symptoms of anxiety, depression or panic.

Cognitive therapy strategies and techniques are designed to deactivate such maladaptive programs, to shift the information processing apparatus (cognitive apparatus) to a more neutral position.

Personality is formed by schemas, or cognitive structures, which represent basic beliefs (attitudes). These schemas begin to form in childhood based on personal experiences and identification with significant others. People form concepts about themselves, others, and how the world works. These concepts are reinforced by further learning experiences and, in turn, influence the formation of other beliefs, values and attitudes.

Schemas can be adaptive or dysfunctional. Schemas are stable cognitive structures that become active when triggered by specific stimuli, stressors, or circumstances.

Cognitive models of emotional and personality disorders

Cognitive model of depression. A. Beck describes the cognitive triad in depression.

1. Negative self-image. A depressed individual perceives himself as maladjusted, worthless, and rejected.

3. Nihilistic view of the future. A depressed individual is convinced that the difficulties he is experiencing are insurmountable. This hopelessness often leads him to suicidal thoughts.

A cognitive model of anxiety disorders. The anxious patient's thinking is dominated by themes of danger, that is, he envisions events that will be detrimental to him, his family, his property, and other values.

Cognitive model of panic disorder. Patients with panic disorder tend to view any unexplained symptom or sensation as a sign of imminent disaster. The main feature of people with panic reactions is the belief that their vital systems - cardiovascular, respiratory, central nervous - will collapse. Because of their fear, they constantly listen to internal sensations and therefore notice and exaggerate sensations that go unnoticed in other people.

Patients with panic disorders have specific cognitive deficit: they are unable to perceive their sensations realistically and interpret them catastrophically.

Patients who have had one or more panic attacks in a particular situation begin to avoid those situations. Anticipation of such an attack triggers a variety of autonomic symptoms, which are then incorrectly interpreted as signs of imminent misfortune (heart attack, loss of consciousness, suffocation), which can lead to a full-blown panic attack. Patients with panic disorder often develop agoraphobia. They end up not leaving their home or limit their activities so much that they cannot go far from home and need to be accompanied.

Cognitive model of phobia. With phobias, there is a premonition of physical or psychological harm in specific situations. If the patient is able to avoid such a situation, he will not feel threatened and will remain calm. If he finds himself in such a situation, he will feel subjective and physiological symptoms of anxiety.

At evaluation phobias there is a fear of failure in social situations, in an exam, or in public speaking. Behavioral and physiological reactions to potential "danger" (rejection, undervaluation, failure) can interfere with the patient's functioning to such an extent that they can cause exactly what the patient fears.

Cognitive model of paranoid states. A paranoid individual attributes prejudicial attitudes toward himself to other people. Other people deliberately insult, interfere, criticize. Unlike depressed patients, who believe that perceived insults or rejection are fair, paranoid patients believe that others are treating them unfairly.

Unlike depressed patients, paranoid patients do not have low self-esteem. They are more concerned with the injustice of perceived attacks and invasions than with actual losses.

Cognitive model of obsessions and compulsions. Patients with obsessions question situations that most people consider safe. Doubt usually concerns situations that are potentially dangerous.

Their main feature is a sense of responsibility and the belief that they are responsible for committing an action that could harm them and their loved ones.

Cognitive model of hysteria. In hysteria, the patient is convinced that he has a somatic disorder. Since the imagined disorder is not fatal, he tends to accept it without much anxiety. Patients suffering from a phobia are essentially “sensory fantasists,” that is, they imagine an illness and then experience a sensory sensation as evidence confirming the presence of that illness. The patient usually experiences sensory or motor abnormalities that correspond to his erroneous belief in organic pathology.

Cognitive model of anorexia nervosa. Anorexia nervosa and bulimia represent constellations of maladaptive beliefs that revolve around one central assumption: “The weight and shape of my body determines my worth and my social acceptability.” Beliefs that revolve around this assumption include, for example, “I will be ugly if I weigh more,” “The only thing in my life that I can control is my weight,” and “If I don’t starve, I will gain weight—” and this is a disaster!

A cognitive model of personality disorders. Disturbed personality is based on genetic predisposition and learning experiences. Each personality disorder is characterized by a core belief and a corresponding behavioral strategy (A. Beck and colleagues). A description of basic beliefs (schemas) and behavioral strategies for various types of personality disorders is given in Table. 8.1.

Table 8.1. Basic beliefs and corresponding behavioral strategies for various types of personality disorders

Cognitive therapy theory

Cognitive, emotional, and behavioral channels interact in therapeutic change, but cognitive therapy emphasizes the central role of cognitions in inducing and maintaining therapeutic change.

Cognitive changes occur at three levels: 1) in voluntary thinking; 2) in continuous, or automatic, thinking; 3) in assumptions (beliefs). Each level differs from the previous one in its accessibility for analysis and stability.

The most accessible for analysis and the least stable are voluntary thoughts, because they can be evoked at will and they are temporary. At the next level are automatic thoughts that appear spontaneously and precede emotional and behavioral reactions. These automatic thoughts are more stable and less accessible than voluntary thoughts, but patients can be taught to recognize and control them. Automatic thoughts arise from assumptions (beliefs) that make up the third level. Beliefs can be very stable and not recognized by patients. Therapy strives to identify these assumptions and counteract their effects.

Let's take a closer look at automatic thoughts and the assumptions (beliefs) that underlie them.

Automatic thoughts- These are thoughts that appear spontaneously and are set in motion by circumstances. These thoughts act between the event or stimulus and the individual's emotional and behavioral responses.

A. Beck gives the following example from clinical practice. A woman who goes outside suddenly realizes that she is three blocks from home and immediately feels ill. Different schools of psychotherapy have different explanations for this mysterious reaction.

Psychoanalysis, for example, explains the weakness that a woman experiences when moving away from home in terms of subconscious meaning: being on the street awakens repressed desires, such as the desire to be seduced or raped. This desire generates anxiety due to the prohibition associated with it.

Behaviorists, using the conditioned reflex model of emotions to explain anxiety, will give reasons of a different kind. They will assume that at some time in her life the woman faced a truly dangerous situation, moving away from home. She developed a conditioned reflex to respond to a harmless stimulus with the same level of anxiety that she would have in the face of real danger.

The cognitive approach offers a different interpretation. A person has a series of thoughts flashing between the exciting event and the emotional consequences. If the patient in our example is able to bridge the gap between the exciting event and the emotional reaction, then the mystery of this reaction becomes clear.

Immediately before the anxiety arose, the following train of thoughts passed through the woman: “I have moved far from home. If something happens to me now, I won’t get home where I can get help. If I fall here on the street, people will just pass by - they don’t know me. Nobody will help me." The chain of reasoning leading to anxiety included a series of thoughts about danger.

Patients are not fully aware of these automatic thoughts. Until the patient is taught to focus on automatic thoughts, they mostly slip through unnoticed.

The automatic thoughts reported by patients have a number of common characteristics. They are specific and separate, appearing in shorthand form. Moreover, they are not the result of deliberation, reasoning or reflection. There is no logical sequence of steps as in goal-oriented thinking or problem solving. Thoughts just “come”, as if reflexively. They are relatively autonomous, meaning the patient makes no effort to trigger them, and they are difficult to “turn off,” especially in severe cases.

Automatic thoughts are perceived as believable. Patients perceive them as uncontroversial without checking their logic or realism. There is no doubt that many of these thoughts are realistic. However, the patient is often inclined to believe unrealistic thoughts, even if he has concluded that they are unfounded when discussed with the therapist. It does not matter how many times external experience refuted these thoughts; they continuously arise in the patient until his recovery.

Assumptions or beliefs. Automatic thoughts, as noted, arise from assumptions or beliefs. Beck also calls these cognitions “rules.” He also uses such definitions as “positions”, “ideas”, “concepts” and “constructions” as synonyms.

Some people's beliefs are dysfunctional. Here is an example of an attitude that many people hold: “I will never be happy unless I become famous.” People who obey this rule are constantly in action: they strive for prestige, popularity, power. Slavish adherence to this rule interferes with other goals such as a reasonable, healthy, calm life, and maintaining pleasant relationships with other people.

Some people become depressed by emphasizing these rules. The sequence is as follows: at first a person believes that he is not getting closer to some illusory goal, for example, fame. A number of conclusions follow from this: “If I didn’t become famous, it means I failed... I didn’t achieve the only thing that is truly worth something... I’m a loser... there’s no point in continuing. You might as well commit suicide.” But if the patient checks the initial premise, he will notice that he has not taken into account other types of satisfaction besides fame. He will also begin to realize how much he has damaged himself by defining his happiness in terms of fame. Also vulnerable to depression are people who define their happiness solely in terms of love from an individual or group of people.

Beck lists some of the attitudes that predispose a person to excessive sadness or depression:

1. In order to be happy, I must always be accepted by everyone (I must evoke love and admiration).

2. In order to be happy, I need to achieve success in any of my enterprises.

3. If I'm not at the top, then I've failed.

4. It's great to be popular, famous, rich; It's terrible to be unpopular, mediocre.

5. If I make a mistake, it means I am an incapable person.

6. My value as a person depends on what others think of me.

7. I can't live without love. If my wife (lover, parents, children) do not love me, then I am worthless.

8. If someone doesn't agree with me, then I'm worthless.

9. If I don't take advantage of every opportunity to advance, I will regret it.

Rules (beliefs) like these are likely to lead to suffering. A person cannot always inspire love in all his acquaintances. The level of love and acceptance fluctuates greatly, but the rules are formulated in such a way that any decrease in love is considered rejection.

There are three main groups of dysfunctional beliefs. The first group includes beliefs related to acceptance (for example: “I have a flaw, therefore I am unwanted”); the second group includes beliefs related to competence (for example: “I am inferior”); the third group includes beliefs related to control (for example: “I cannot exercise control”).

Cognitive distortions

Cognitive biases are systematic errors in judgment. They arise from dysfunctional beliefs embedded in cognitive schemas and are easily detected by analyzing automatic thoughts.

Personalization. It is the tendency to interpret events in terms of personal meaning. The process of personalization is best illustrated by extreme examples involving psychotic patients. A patient suffering from paranoid schizophrenia believed that the images he saw on the television screen spoke directly to him, and he responded to them. A depressive psychotic, hearing about an epidemic in a distant country, began to reproach himself for causing it. A manic woman was convinced when she went out into the street that all the men passing by were in love with her. Psychotic patients constantly interpret events that are completely unrelated to them, as if they themselves caused these events or as if the events were directed against them personally.

Milder forms of personalization are found in neurotic patients. They tend to overestimate the extent to which events relate to them. They are also overly preoccupied with the personal meanings of individual incidents. A depressed neurotic, seeing the frown of a passerby, thinks: “He feels disgusted with me.” Although it may turn out that in this case the patient’s opinion is correct, his mistake lies in the idea that any grimace he notices in others indicates disgust towards him. He overestimates both the frequency and degree of negative feelings he evokes in other people.

Dichotomous thinking. A neurotic patient tends to think in extremes in situations that hit him in sensitive areas, for example, in terms of self-esteem - in depression, in the likelihood of being in danger - in anxiety neurosis. Events are labeled as black or white, good or bad, beautiful or terrible. This property has been called “dichotomous thinking” or “bipolar thinking.” For example, a student thinks: “If I don’t pass the exam with an A, I’m a failure.”

Selective abstraction. It is the conceptualization of a situation based on details extracted from the context, while ignoring other information. For example, at a noisy party, a guy begins to be jealous of his girlfriend, who bowed her head to another in order to hear him better.

Arbitrary conclusions. Inferences that are unproven or even contradict obvious facts. An example would be a working mother who, at the end of a hard day, concludes: “I’m a terrible mother!”

Overgeneralization. This is an unjustified generalization based on a single case. For example, a child makes one single mistake, but thinks: “I’m doing everything wrong!” Or a woman concludes after a discouraging date: “All men are the same. I will always be rejected."

Exaggeration (dramatization, catastrophization). Catastrophization is an exaggeration of the consequences of any event. Examples include the following patient assumptions: “It would be terrible if someone had a bad opinion of me,” “If I’m nervous during the exam, it would be terrible!”

Goals and main strategies of cognitive therapy

The goals of cognitive therapy are to correct faulty information processing and help patients modify beliefs that support maladaptive behavior and emotions. Cognitive therapy initially aims to relieve symptoms, including problem behavior and logical biases, but its ultimate goal is to eliminate systematic biases in thinking.

Cognitive therapy treats the patient's beliefs as hypotheses that can be tested through a behavioral experiment; A behavioral experiment is a test of distorted beliefs or fears in real life situations. The cognitive therapist does not tell the patient that his beliefs are irrational or wrong or that he needs to accept the therapist's beliefs. Instead, the therapist asks questions to elicit information about the meaning, function, and consequences of the patient's beliefs, and the patient then decides whether to reject, modify, or retain his beliefs after first recognizing their emotional and behavioral consequences.

Cognitive therapy is designed to teach patients to:

a) control dysfunctional (irrational) automatic thoughts;

b) be aware of the connections between cognitions, affects and behavior;

c) explore the arguments for and against dysfunctional automatic thoughts;

d) replace dysfunctional automatic thoughts with more realistic interpretations;

e) identify and change beliefs that predispose to distortion of experience.

Cognitive therapy uses cognitive and behavioral techniques to address these issues.

A. Beck formulates three main strategies Cognitive Therapy: Collaborative Empiricism, Socratic Dialogue, and Guided Discovery.

Empiricism of cooperation is that the therapist and patient are collaborators in exploring facts that support or refute the patient's cognitions. As in scientific research, interpretations or assumptions are considered hypotheses to be tested.

Empirical evidence is used to determine whether cognitions serve any useful purpose. Initial conclusions are subjected to logical analysis. Bias-based thinking will become apparent to the patient when he becomes aware of alternative sources of information. This process is a partnership between patient and therapist.

Socratic dialogue. Conversation is the main therapeutic tool in cognitive therapy, and the Socratic type of dialogue is widely used. The therapist carefully crafts questions to facilitate new learning. The purposes of these questions are: 1) to clarify or define problems; 2) help the patient identify thoughts, images, assumptions; 3) explore the meaning of events for the patient; 4) assess the consequences of maintaining maladaptive thoughts and behavior.

Recall that the essence of Socratic dialogue is that the patient comes to logical conclusions based on questions posed by the therapist. Questions are not used to “trap” the patient into an inevitable conclusion; they are placed so that the patient can look at his assumptions objectively, without resorting to defense.

Guided discovery. Through guided discovery, the patient modifies maladaptive beliefs and assumptions. The therapist serves as a “guide”: he clarifies problematic behavior and logical errors, creating new experiences through behavioral experiments. These experiences lead to the acquisition of new skills and attitudes. Through cognitive and behavioral techniques, the patient discovers adaptive ways of thinking and behaving. The patient learns to correct faulty cognitive processing of information so that he eventually becomes independent of the therapist. Guided discovery implies that the therapist does not encourage the patient to accept a new set of beliefs; The therapist encourages the patient to use information, facts, and opportunities to develop a realistic view.

Cognitive techniques

Cognitive techniques are used, firstly, to identify and subsequently correct automatic thoughts, and secondly, to identify maladaptive assumptions (beliefs) and study their validity.

Identifying automatic thoughts. A method called filling the void. The procedure is explained to the patient using the sequence A, B, C: A is an exciting event; C – excessive, inadequate “conditioned reaction”; B is an emptiness in the patient's mind, which, when filled by the patient himself, serves as a bridge between A and C. The therapeutic task becomes filling the emptiness through elements of the patient's belief system. For example, one patient described the following sequence: A – meeting with an old friend, C – sadness. Then the patient was able to gradually reconstruct the event and remember the thoughts that arose in the interval. A meeting with an old friend brought out the following chain of thoughts (B): “If I say hello to him, he may not remember me... So much time has passed, we have nothing in common... He may besiege me... The meeting will not be like the previous ones.” These thoughts caused a feeling of sadness.

Filling the Void can be of great help to patients whose disorder involves excessive feelings of shame, anxiety, anger, or sadness in interpersonal situations. For example, one student avoided social gatherings due to unexplained feelings of shame, anxiety, and sadness. After learning to recognize and record his cognitions, he reported having the following thoughts in social situations: “Nobody wants to talk to me... everyone thinks I look pathetic... I just don't fit in socially.” After these thoughts, he began to feel humiliated, feel anxious and sad, and had a strong desire to run away.

The cognitive sphere includes images in addition to thoughts. Some patients find it easier to report vivid images than thoughts. This often happens with anxious patients. One study found that 90% of anxious patients reported visual imagery preceding an anxious episode. A woman who was afraid to walk alone saw pictures of a heart attack, death on the street, after which she experienced acute anxiety. Another woman, who felt a wave of anxiety while crossing a bridge, admitted that the anxiety was preceded by picturesque images of a car flying over the fence. Collecting information about images is therefore another way of understanding conceptual systems.

Automatic thoughts are tested through direct evidence or logical analysis. Evidence can be obtained from past or present circumstances. Evidence can also be obtained from the results of behavioral experiments. Such experiments enable the patient to refute a previous belief. For example, if a person is convinced that he cannot enter into contact with other people, then he may try to talk to people unfamiliar to him. The empirical nature of behavioral experiments allows patients to think more objectively.

Exploring the patient's thoughts may lead to cognitive change. Conversation can reveal logical inconsistencies, inconsistencies, and other errors in thinking. Identifying and categorizing cognitive distortions is in itself useful because patients identify errors that they can then correct.

Cognitive techniques, as already indicated, are also used to identify and explore maladaptive assumptions (beliefs), which are usually much less accessible to patients than automatic thoughts. Only some patients are able to formulate their beliefs, while most have difficulty. Beliefs serve as themes for automatic thoughts. The therapist may invite the patient to extract the rules underlying his automatic thoughts. The therapist may also make assumptions based on these data and present their assumptions to the patient for confirmation. Patients have the right to disagree with the therapist and to find more precise formulations of their beliefs.

If an assumption (belief) is identified, then it is open to modification, which is done in several ways: a) you can ask the patient whether the belief is reasonable, b) ask the patient to give reasons for and against maintaining this belief, c) provide evidence, facts that contradict this belief, that is, refute it.

Correcting automatic thoughts includes decatastrophizing, reattribution, reformulation, and decentralization.

Decatastrophization. We have already said that catastrophizing is an exaggeration of the consequences of negative events. Most of the patients' problems arise in the context of interpersonal relationships. The most common bias of anxious people is: “It would be terrible if someone had a bad opinion of me.” Patients are usually most afraid of being judged poorly by peers, classmates, coworkers, or friends. However, many patients are even more afraid of the prospect of appearing funny to strangers. They anxiously anticipate reactions from store clerks, waiters, taxi drivers, bus passengers, or passers-by on the street.

A person may be afraid of a situation in which he finds himself, in his opinion, vulnerable to criticism from other people. He is sensitive to situations in which he is capable of showing some kind of “weakness” or “mistake.” He often fears disapproval for being different from others. The patient has a vague idea that denial or criticism is somehow damaging to his self-image.

Decatastrophizing, or as it is also called, the “what if” technique, is intended to examine actual, factual events and consequences that, in the patient’s mind, cause him psychological harm and cause feelings of anxiety. This technique helps patients prepare for fearful consequences. It is useful for reducing avoidance.

A. Beck gives the following example of the use of decatastrophization in a student who became inhibited in various situations that required defending his Self, for example, asking directions from a stranger, checking a cash duplicate of his account, refusing someone’s request, asking someone for a favor, speak in front of an audience.

Patient. I have to speak to my group tomorrow and I'm scared to death.

Therapist. What are you afraid of?

Patient. I think I'll look like a fool.

Therapist. Let's assume you really will look like a fool. What's bad about it? Patient. I won't survive this.

Therapist. But listen, suppose they laugh at you. Are you really going to die from this? Patient. Of course not.

Therapist. Suppose they decide that you are the worst speaker that ever existed... Will that ruin your future career?

Patient. No... But it's good to be a good speaker.

Therapist. Of course not bad. But if you fail, will your parents or wife really disown you?

Patient. No... they will be sympathetic.

Therapist. So what's the worst thing about this?

Patient. I'll feel bad.

Therapist. How long will you feel bad?

Patient. A day or two.

Therapist. And then?

Patient. Then everything will be in order.

Therapist. You are afraid that your destiny is at stake.

Patient. Right. I feel like my entire future is at stake.

Therapist. So, somewhere along the way, your thinking fails... and you tend to view any failure as if it were the end of the world... You need to actually label your failures as failures to achieve a goal, rather than as a terrible disaster. You need to start challenging your false premises.

In the next session - after the patient had given a speech which, as he had anticipated, was somewhat upset by his fears - his ideas about failure were examined.

Therapist. How are you feeling now?

Patient. I'm feeling better... but I've been broken for a few days.

Therapist. What do you think now about your opinion that awkward speech is a disaster?

Patient. Of course, this is not a disaster. It's unpleasant, but I'll get through it.

Next, work was carried out with the patient to change his idea of failure as a catastrophe. Before his next performance a week later, he had much less apprehension and felt less discomfort during the performance. At the next session, the patient completely agreed that he attached too much importance to the reactions of his comrades. The following conversation took place.

Patient. During the last performance I felt much better... I think it's a matter of experience.

Therapist. Have you had any glimmer of awareness that most of the time it doesn't really matter what people think of you?

Patient. If I'm going to become a doctor, I need to make a good impression on my patients.

Therapist. Whether you are a bad doctor or a good one depends on how well you diagnose and treat your patients, not on how well you perform in public.

Patient. Okay... I know that my patients are doing well, and I think that's what matters.

The final part of the treatment was devoted to addressing those maladaptive beliefs of the patient that caused discomfort in other situations. The patient reported a new position he had come to: “I now see how ridiculous it is to worry about the reactions of complete strangers. I'll never see them again. So, what difference does it make what they think of me?”

Reattribution. These are techniques that test the validity of automatic thoughts and beliefs by considering alternative causes of events. Reattribution is especially useful in cases where patients perceive themselves as the cause of events (the phenomenon of personalization) or, in the absence of evidence, attribute the cause of the event to another person or some single factor. Reattribution techniques involve checking reality and examining all the factors that influenced the situation.

Reformulation. This technique is designed to mobilize a person who believes that the problem is out of his control. For example, a lonely person who thinks, “No one pays attention to me,” is encouraged to reframe the problem: “I need to reach out to other people to take care of me.” When formulating a problem in a new way, it is necessary to ensure that it receives a more concrete and specific sound; in addition, it must be defined in terms of the patient's behavior.

Decentralization. In various psychological disorders - anxiety, depression, paranoid states - the main distortion of thinking stems from the patient's tendency to personalize events that have nothing to do with him. The method of freeing the patient from the tendency to see himself as the point of concentration of all events is called decentralization. To check the distorted beliefs of patients, it is proposed behavioral experiments. For example, one student who preferred to remain silent in class believed that his classmates were constantly watching him and noticing his anxiety. He was encouraged to observe them instead of focusing on his discomfort. When he saw that some students were taking notes, others were listening to the professor, and others were daydreaming, he came to the conclusion that his comrades were preoccupied with other matters.

Identification and correction of dysfunctional beliefs (positions, schemes). These beliefs, as indicated, are less accessible to analysis than automatic thoughts. Patients' beliefs can be judged by the direction of their automatic thoughts. Additional sources for the formation of hypotheses related to beliefs are the behavior of patients, their strategies for overcoming difficulties, and personal stories. Patients often find it difficult to formulate their beliefs without the therapist's help, so the therapist presents hypotheses to patients for testing. To correct beliefs, the therapist can:

1. Ask patients questions to encourage exploration of beliefs. For example: “Is this belief reasonable?”, “What are the advantages and disadvantages associated with holding this belief?”

2. Organize cognitive experiment, during which patients test the truth of their beliefs. For example, Beck's patient, fearing that she could not trust her husband, constantly found fault with him, causing their relationship to become increasingly estranged. Her core belief was: “There is no way I can allow myself to be vulnerable.” Beck proposed a three-month experiment to test her hypothesis: “If I devote myself completely to improving my relationship with my husband, if I look for the positive instead of the negative, I will feel more secure.” As a result, the patient found that she became more confident and began to think less about divorcing her husband.

3. Use imagery to help patients relive past events and restructure their experiences and resulting beliefs.

4. Use the childhood experience of patients with personality disorders to revise their beliefs formed during the period under review, in the process of role-playing with changing roles.

5. Help patients re-form beliefs, replacing dysfunctional beliefs with more constructive ones. This technique is one of the central ones in rational-emotive therapy by A. Ellis.

Behavioral techniques

Cognitive therapy uses behavioral techniques to modify automatic thoughts and assumptions (beliefs). It uses behavioral experiments designed to challenge specific maladaptive beliefs and produce new learning. In a behavioral experiment, the patient predicts an outcome based on automatic thoughts before starting the experiment, then performs a behavior previously agreed upon with the therapist, and finally evaluates the outcome in the light of new experience.

Behavioral techniques are also used to: expand the patient’s repertoire of behavioral reactions (skills training); relaxation (progressive relaxation); stimulation of activity (activity planning); preparing the patient for situations that cause anxiety (behavioral rehearsal); presentation of fear-inducing stimuli (exposure therapy).

Since behavioral techniques are used for cognitive change, it is very important to know the patient's perceptions, thoughts and conclusions after each behavioral experiment.

Homework gives patients the opportunity to apply cognitive principles between sessions. Typical homework involves self-observation and self-control, structuring time effectively and following procedures relevant to specific situations. Self-monitoring is applied to the patient's automatic thoughts and reactions in various situations. New cognitive skills, such as challenging automatic thoughts, are also practiced at home.

Hypothesis testing. This technique has both cognitive and behavioral components. When constructing a hypothesis, it is necessary to make it specific and specific. You cannot use generic labels, unclear terms, or vague concepts. For example, one of the patients, a doctor by profession, doubted his professionalism. The therapist asked to list the arguments in favor of this conclusion. When listing, the patient did not take into account factors such as rapport with patients and the ability to make decisions in a situation of time pressure. These criteria were added by the therapist. The patient was then asked to monitor his behavior and ask for feedback from his peers and supervisors to test his hypothesis. As a result, the patient came to the conclusion that he was “after all a good professional.”

Behavior rehearsal and role play used to train skills or techniques that will later be used in vivo. Simulation is also used in skill training. Role-playing is often recorded on a video recorder to provide an objective source of information for evaluating performance.

Distraction Techniques designed to reduce strong emotions and negative thinking. This includes physical activity, social contacts, work, play.

Tasks with gradual complication of the task. This technique involves initial activity at a safe level, with the therapist gradually increasing the difficulty of the tasks. For example, a patient who has difficulty communicating may begin to interact with one person or a small group of acquaintances, or may communicate with people for a short period of time. Then, step by step, the patient increases the time he spends with others.

Exposure therapy provides information about the thoughts, images, psychological symptoms and level of tension experienced by the anxious patient. Specific thoughts and images can be examined for distortions, after which patients can be taught specific coping skills.

Activity planning. This procedure boils down to following a daily routine and assessing the performance of a particular activity (using a scale from 0 to 10) and the degree of satisfaction from this activity. Planning activities leads, for example, to the fact that patients who previously believed that their depression was kept at a constant level see mood swings; patients who believe that they cannot perform or receive satisfaction from any activity are convinced otherwise; patients who believe that they are inactive because of an inherent defect see that activity can be planned and that it has a reinforcing effect.

Application of cognitive therapy

Cognitive therapy is a present-centered approach. She is directive, active, and problem oriented.

Originally used in an individual setting, cognitive therapy is now used in family and couples therapy, as well as in a group setting. It can be used in combination with pharmacotherapy in outpatient and inpatient settings.

Cognitive therapy is widely used to treat emotional disorders and unipolar depression. Studies comparing the effectiveness of cognitive therapy and antidepressant therapy have shown that cognitive therapy has better results or at least the same as antidepressant therapy. Follow-up studies lasting from three months to two years have shown that long-term treatment results are better with cognitive therapy than with pharmacological treatment.

Cognitive therapy is the therapy of choice in cases where the patient refuses medication and prefers psychological treatment. It is also the treatment of choice in cases where the patient has side effects from antidepressants or when the patient is resistant to antidepressant treatment.

Case from practice

This case demonstrates the use of both behavioral and cognitive techniques in the treatment of a patient with an anxiety disorder.

Presentation of the problem. The patient, a 21-year-old college student, complained of difficulty falling asleep and waking up frequently, stuttering, body tremors, nervousness, dizziness, and restlessness. Sleep problems became especially acute before exams or sports competitions. He explained his speech problems by the fact that it was difficult for him to find the “right word.”

The patient grew up in a family that valued competition. The patient's parents encouraged competition among his siblings. Since he was the eldest child, he was expected to win all competitions. Parents believed that children should surpass them in achievements and successes. They identified so strongly with their son’s achievements that he believed: “My success is their success.”

Parents also encouraged competition with children outside the family. My father reminded me: “Don’t let anyone be better than you.” As a result of the fact that the patient saw his peers as his rivals, he had no friends. Feeling lonely, he desperately tried to attract friends with all sorts of pranks and tall tales in order to exalt his image and make his family more attractive. Although he had acquaintances in college, he had few friends because he could not reveal himself for fear that others would discover that he was not what he wanted to be.

Start of therapy. After gathering information regarding diagnosis, situation, and history, the therapist attempted to determine how the patient's cognitions contributed to his distress.

Therapist. What situations upset you the most?

Patient. When I fail in sports. Especially in swimming. And also when I make mistakes, even when playing cards with the guys in the room. I get very upset if a girl rejects me.

Therapist. What thoughts run through your head when, say, you fail at something in swimming?

Patient. I think that people pay less attention to me if I'm not at my best, not a winner.

Therapist. What if you make mistakes when playing cards?

Patient. Then I doubt my intellectual abilities.

Therapist. What if a girl rejects you?

Patient. This means that I am ordinary... I am losing value as a person.

Therapist. Don't you see the connection between these thoughts?

Patient. Yes, I think my mood depends on what other people think of me. But this is so important. I don't want to be lonely.

Therapist. What does it mean to you to be single?

Patient. This means that there is something wrong with me, that I am a failure.

At this point, the therapist begins to hypothesize about the patient's beliefs: his worth is determined by others, he is unattractive because he is inferior, he is a failure. The therapist looks for evidence that these beliefs are central, but remains open to other ideas.

The therapist assists the patient in developing a list of therapy goals that include: 1) reducing perfectionism; 2) reducing anxiety levels; 3) improved sleep; 4) increased intimacy in friendship; 5) development of one’s own values, independent of parental ones. The problem of anxiety was taken up first to be solved. The upcoming exam was chosen as the target situation. The patient studied for the exam much more than was required, went to bed exhausted, had difficulty falling asleep, woke up in the middle of the night, thinking about the upcoming exam and its possible consequences, and went to the exam in the morning exhausted. To reduce mental chewing about the exam, the therapist asked the patient to list the benefits of it.

Patient. Well, if I don't think about the exam, I might forget something. If I constantly think, I will be better prepared.

Therapist. Have you ever been in a situation where you were “underprepared”?

Patient. Not in the exam, but I once took part in a big swimming competition and was with friends the night before and wasn't thinking. I returned home, went to bed, and in the morning I got up and went swimming.

Therapist. So how did it turn out?

Patient. Wonderful! I was in shape and swam pretty well.

Therapist. Based on this experience, do you think there is reason to worry less about your performance?

Patient. Yes, probably. It didn't hurt me that I didn't worry. In fact, my anxiety only makes me sad.

Thanks to his own reasonable explanation, the patient was able to abandon the constant grinding of thoughts about performance. He was then ready to give up his maladaptive behavior and take the risk of trying something new. The therapist taught the patient progressive relaxation, and the patient began using it to reduce anxiety.

It was also explained to the patient that cognitions influence behavior and mood. Taking up the patient's assertion that anxiety can be upsetting, the therapist continued working.

Therapist. You mentioned that when you worry about exams, you experience anxiety. Now try to imagine that you are lying in bed the night before an exam.

Patient. Okay, I'm ready.

Therapist. Imagine thinking about an exam and deciding that you didn't prepare enough. Patient. Yes, I did.

Therapist. What do you feel?

Patient. I feel nervous. My heart starts pounding. I think I need to get up and exercise some more.

Therapist. Fine. When you think you are unprepared, you become anxious and want to get up. Now imagine lying in bed the night before an exam and thinking about how well you prepared and knew the material.

Patient. Fine. Now I feel confident.

Therapist. Here! Do you see now how your thoughts affect your feelings of anxiety?

The patient was asked to record automatic thoughts and recognize and respond to cognitive distortions. As homework, he was asked to write down automatic thoughts if he had difficulty falling asleep before an exam. One of the automatic thoughts was: “I’ll probably think about the exam again.” His answer was: “Now thoughts about the exam no longer matter. I'm prepared." Another thought: “I need to sleep now! I need eight hours of sleep!” and the answer: “I left time in reserve, so I have it. Sleep is not so important to worry about.” He managed to shift his attention and thoughts to a positive image: he imagined himself floating in clear blue water.

By observing his automatic thoughts in various situations (academic, sports, social), the patient learned to recognize dichotomous thinking (“with a shield or on a shield”) as a common cognitive distortion. When working with dichotomous thinking, two techniques helped the patient: transforming (reframing) the problem and creating a continuum between dichotomous categories. The patient's problem was transformed as follows.

Therapist. If someone ignores you, could there be other reasons than that you are a loser?

Patient. No. If I can't convince them that I'm important, I won't be able to attract them.

Therapist. How do you convince them of this?

Patient. To tell the truth, I exaggerate my successes. I lie about my grades in class or say I won a competition.

Therapist. And how does it work?

Patient. Not very good actually. I am embarrassed and they are embarrassed by my stories. Sometimes they don't pay much attention, sometimes they leave me after I say too much about myself.

Therapist. So in some cases they reject you when you attract their attention to you?

Patient. Yes.

Therapist. Does it have anything to do with whether you're a winner or a loser?

Patient. No, they don't even know who I am inside. They just turn away because I talk too much.

Therapist. Yes. It turns out that they react to your speaking style.

The therapist moves the problem from a situation in which the patient reveals his inferiority to a situation characterized by a problem of social skills. (Input: “I’m being ignored because I’m a loser”; output: “I’m being ignored because my communication style doesn’t suit people.”) Moreover, the theme “I’m a loser” turned out to be so relevant for the patient that he calls it "the main belief." This assumption can be traced historically and its roots can be found in the parents' constant criticism of his mistakes and shortcomings. By analyzing his history, he was able to see that his lies prevented people from getting close to him and thereby reinforced his belief that they did not want to be friends with him. In addition, he believed that he owed all his success to his parents and not a single achievement was only his achievement. This made him angry and led to a lack of self-confidence.

Further treatment. As therapy progressed, homework assignments focused on social interaction. He learned to start conversations and ask questions to learn more about other people. He also learned to restrain himself when the urge to embellish himself arose. He learned to control the reactions of others to himself and discovered that, although they were different, they were generally positive. While listening to others, he noticed that he admired people who openly admitted their shortcomings and ridiculed their mistakes. This experience helped him understand that there is no point in dividing people, including himself, into “winners” and “losers.”

In recent sessions, the patient expressed the belief that his behavior reflected on his parents and vice versa. He said, "If they look good, it says something about me, and if I look good, it's a credit to them." In one task, he was asked to list the characteristics that distinguish him from his parents. He noted: "Understanding that my parents and I are different people makes me realize that I can stop lying." Understanding that he was different from his parents freed him from their absolutist standards and allowed him to become less shy when interacting with others.

As a result of therapy, the patient developed interests and hobbies that are not related to achievements. He began to set moderate and realistic goals for his education and began dating a girl.