Cognitive-behavioral psychotherapy. Cognitive Behavioral Therapy

28. Cognitive-behavioral psychotherapy

cognitive-behavioral approach in psychotherapy suggests that human problems stem from distortions of reality based on misconceptions, which, in turn, arose as a result of incorrect learning in the process of personality development. Therapy is about looking for distortions in thinking and learning an alternative, more realistic way of seeing your life. The K-B approach works when you need to find new forms of behavior, build the future, consolidate the result. Representatives of the modern cognitive-behavioral approach - A. T. Beck, D. Maikhenbaum.

Initially, the approach was formed on the development of ideas behaviorism. Behaviorism as a theoretical direction of psychology arose and developed at about the same time as psychoanalysis, from the end of the 19th century, attempts to systematically apply the principles of learning theory for psychotherapeutic purposes date back to the late 50s and early 60s. At this time in England, in the famous Model Hospital, G. Eysenck first applied the principles of learning theory to the treatment of mental disorders. In clinics in the United States, a technique of positive reinforcement of desired responses in patients with severely disturbed behavior, the so-called "saving tokens" technique, is beginning to be widely used. All positively assessed actions of patients receive reinforcement in the form of issuing a special token. The patient can then exchange this token for sweets or get a day off to visit the family, etc.

At this time it happens cognitive revolution in psychology, proving the role of so-called internal variables, or internal cognitive processes, in human behavior. Psychotherapy, which arose on the basis of behaviorism, became a name. behavioral-cognitive.

Types of therapy based on the cognitive-behavioral approach:

1. Directions closer to classical behaviorism and based mainly on the theory of learning, that is, on the principles of direct and hidden conditioning. This is actually behavioral psychotherapy, and from the Russian approaches to this group of methods, Rozhnov's emotional-stress psychotherapy can be attributed.

2. Directions based on the integration of the principles of learning theory and information theory, as well as the principles of reconstruction of the so-called dysfunctional cognitive processes and some principles of dynamic psychotherapy. These are, first of all, rational-emotive psychotherapy by Albert Ellis and cognitive psychotherapy by Aron Beck. This also includes the approaches of V. Guidano

3. Other directions, such as rational psychotherapy, short-term multimodal psychotherapy, etc.

29. Model of mental pathology in existential-humanistic psychology

Humanistic psychologists believe that people have an innate tendency towards friendship, cooperation and creativity. Human beings, these theorists claim, seek self-actualization—the realization of this potential for goodness and growth. However, they can achieve this only if, along with their merits, they honestly recognize and accept their shortcomings and determine satisfactory personal values ​​that should be guided in life.

Self-actualization is a humanistic process in which people realize their potential for goodness and growth.

Existentially oriented psychologists agree that people should have accurate representation about themselves and live a meaningful "authentic" life in order to be psychologically well adjusted. However, their theories do not suggest that people are naturally inclined to live in a positive way. These theorists believe that we are born with complete freedom: either to openly look at our existence and give meaning to our lives, or to evade this responsibility. Those who choose to "hide" from responsibility and choice will begin to view themselves as helpless and weak, and as a result, their lives can become empty, inauthentic, and lead to the appearance of certain symptoms.

Both the humanistic and existential view of pathology date back to the 1940s. During this time, Carl Rogers, often regarded as a pioneer of the humanist movement, developed a client-centered, client-accepting, supportive approach that contrasted sharply with the psychodynamic techniques of the time. He also put forward a theory of personality that did not give much importance to irrational instincts and conflicts.

The existential view of personality and pathology arose during the same period. Many of its principles are based on the ideas of 19th-century European existentialist philosophers who believed that people constantly determine their existence through their actions, and thus give meaning to it. In the late 1950s, May, Angel, and Ellenberger published a book called Existence, which outlined several basic existential ideas and healing approaches, which helped to draw attention to this trend.

It can be carried out in different directions. One of the most relevant and developing trend today is cognitive-behavioral therapy.

The basis of this method is the acceptance that the causes of problems must be sought in oneself, in one's own thoughts and assessment of others, as well as oneself. Emotional reactions of a negative nature appear as a response to a certain situation only because there is some kind of internal assessment in the deep consciousness of a person. To solve the problem, you will need to change the assessment of a difficult situation.

Differences of behavioral (behavioral) therapy from other areas of psychology

Any kind of psychotherapy is aimed at changing the personality of the patient. This is a deep work that requires a great return from the psychotherapist. Exists a large number of areas of psychotherapy, each of which has its own characteristics:

Gestalt therapy puts forward the "I" of the patient in the first place, calling to satisfy their needs and desires at the moment of their occurrence by any socially acceptable means. It is believed that various kinds psychological problems arise in a person when he does not follow his desires, but tries to meet the ideal imposed on him by the people around him;

Psychoanalysis evaluates the patient's dreams, as well as the associations that various objects, people and situations evoke;

Art therapy allows you to solve psychological problems through the impact of artistic methods. The patient is offered to draw, sculpt, etc.

There are also other directions, but only behavioral therapy will allow a person to discover irrational logic and warnings in the deep consciousness.

align="justify">Internal beliefs are challenged and re-evaluated. To achieve such results, the psychotherapist asks the patient a lot of different issues, some of them are tricky, others are funny or just plain idiotic.

As a result, cognitive behavioral therapy the psychologist's patient gets the opportunity to look at his inner beliefs from the outside and understand the absurdity of some of them. Revising your assessment of the world around you, people and yourself allows you to get rid of such psychological disorders as depression and anxiety, as well as increase self-esteem and self-confidence.

Methods used in cognitive-behavioral psychotherapy

All sessions of therapy according to this method take place in the form of a conversation, during which the patient is invited to conduct experiments and answer a series of questions. It could be individual therapy or group sessions, which are more like training aimed at improving psychological state patient now and in the future.

Cognitive Behavioral Therapy mental disorders carried out using the following methods:

1. Cognitive restructuring can reduce the patient's anxiety. This is achieved by assessing your fears and reality. The client of the psychotherapist independently fills out a table in which the situation that frightens him fits. Then he is asked to predict several worst-case scenarios. When this stage is completed, it is necessary to recall similar situations from the past and describe their real outcome. For greater clarity, fears are assigned a probability coefficient in percent, after which the patient can see that his worst fears were not justified.

2. Socratic (Socratic) dialogue can be used not only during psychotherapy, but also in any other conversation. This method was used by Socrates during his studies with his students. First you need to agree with the opponent, then question his correctness, and then argue your thoughts. Skillful use of this method allows you to resolve any controversial situation.

3. The cognitive continuum allows you to work with polar thinking. Relatively speaking, patients are sure that there is only white and black, but during the session it turns out that there are many shades of gray.

4. ABC analysis. Every situation that happens to us in life (A) leads to the emergence of thoughts and internal conversation(IN). Depending on internal beliefs, a reaction (C) arises. In the scheme A→B→C leading role our beliefs play, it is on them that the thoughts that arise in response to the situation, leading to negative or positive emotions, depend.

Also, psychotherapists practicing the cognitive-behavioral method of correcting mental disorders use other methods in their work. This area is actively developing, there are new works, developments and techniques.

Cognitive behavioral (cognitive behavioral) therapy is a type of psychotherapy. This form of psychotherapy changes the mindset to change mood and behavior. It is based on the idea that negative actions or feelings are the result of current distorted observations or thoughts, and not unconscious forces from the past.

CBT is a mixture of cognitive and behavioral approaches. Cognitive therapy focuses on your mood and thoughts. Behavioral therapy - on actions and behavior. A holistic therapist works with you on a structured mindset. You and your therapist work to identify specific patterns negative thoughts and behavioral responses to difficult or stressful situations.

Treatment involves developing more balanced and constructive ways to respond to stressors. Ideally, these new ways should help minimize or eliminate anxious behavior or illness.

The principles of CBT can also be applied outside of the therapist's office. For example, CBT Online: uses CBT principles to help manage symptoms of depression and anxiety.

How CBT Works

CBT is a shorter term approach than psychoanalytic and psychodynamic therapy. Other types of therapy may take several years to discover a patient and treat him. CBT often involves only 10-20 sessions.

The sessions provide an opportunity to identify current life situations that may be causing or contributing to depression. You and your therapist are looking for patterns or thought patterns that lead to depression.

This therapy is different from psychoanalysis. It also includes working with your past to find the sources of the problems you face.

You may be asked to keep a diary as part of CBT. The journal assumes that you write down any events and your reactions to them. A therapist can help you break negative patterns and reactions, such as:

• all-or-nothing thinking: seeing the world in black and white
• rejection of positive experience, insisting that it "does not count" for whatever reason

• automatic negative reactions: habitual swearing thoughts
• increase or decrease the value of an event:
• overgeneralization: drawing broad conclusions from a single event
• personalization: taking things too personally or feeling actions as if they were directed at you
• mental filter: choosing one negative detail and fixating on it in such a way that reality is obscured

You and your doctor can use a mood diary to help replace negative behaviors or perceptions with more constructive ones. This can be done using a number of methods such as:

• control and modification of distorted thoughts and reactions
• training in an accurate and comprehensive method for assessing external situations and reactions or emotional behavior
• practice of self-reflection

You can practice these techniques on your own or with the help of a therapist. Alternatively, you can practice in controlled environments where you are facing a problem. You can use these situations to develop the ability to respond to all events calmly. Another way is online CBT. This allows you to practice the techniques at home or in the office.

What diseases are treated with CBT?

Cognitive Behavioral Therapy is widely used to treat various diseases and conditions in children, adolescents and adults. These diseases and conditions include:

• antisocial behavior (including lying, stealing, harming animals and people)
• anxiety disorders
• attention deficit hyperactivity disorder
• bipolar disorder
• conduct disorders
• depression
• eating disorders (binge eating, anorexia, bulimia)
• stress
• personality disorders
• phobias
• schizophrenia
• sexual disorders

• sleep disorders
• problems with social skills
• alcohol or drug abuse

CBT can be combined with other treatments for depression.

Are there any risks?

There is little long-term emotional risk associated with CBT. But turning to painful feelings and experiences is always stressful! Treatment may include situations that you have previously avoided. For example, you may be asked to spend more time in public places if you are afraid of people. Maybe you have to face death loved one that made you depressed.

These scenarios provide an opportunity to practice the acquired skills in stressful situations. The goal of therapy is to teach you how to deal with anxiety and fear in a safe and constructive manner.

What do the experts say?

“There is a huge amount of evidence for the effectiveness of CBT for specific problems,” Simon Rego, a psychotherapist at Montefiore Medical Center in New York, told us. “There is not much evidence for other therapies.”

This does not mean that other therapies are ineffective. “They're harder to learn,” says Rego. “Most of the research has just been done on the basis of CBT.”

Cognitive Behavioral Psychotherapy, Also Cognitive Behavioral Psychotherapy(English) cognitive behavioral therapy) - general concept describing psychotherapies based on the premise that psychological disorders (phobias, depression, etc.) are caused by dysfunctional beliefs and attitudes.
The basis of this area of ​​psychotherapy was laid by the works of A. Ellis and A. Beck, which also gave impetus to the development of a cognitive approach in psychology. Subsequently, behavioral therapy methods were integrated into the methodology, which led to the current name.

The founders of the system

In the middle of the 20th century, the works of the pioneers of cognitive behavioral therapy (hereinafter referred to as CT) A. Beck and A. Ellis gained great fame and distribution. Aaron Beck originally received a psychoanalytic training, but, disillusioned with psychoanalysis, created his own model of depression and new method treatment affective disorders called cognitive therapy. He formulated its main provisions independently of A. Ellis, who developed a similar method of rational-emotional psychotherapy in the 50s.

Judith S. Beck. Cognitive Therapy: complete guide: Per. from English. - M .: LLC "Publishing House "Williams", 2006. - S. 19.

Goals and objectives of cognitive therapy

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 among themselves, share a common fundamental assumption: the patient is tormented by hidden forces over which he has no control. …

These three leading schools maintain that the source of the patient's disorder lies 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 resolving psychological problems is in the minds of patients.

Alexandrov A. A. Modern psychotherapy. - St. Petersburg: Academic project, 1997. - S. 82.

There are five goals of cognitive therapy: 1) reduction and / or complete elimination of the symptoms of the disorder; 2) reducing the likelihood of relapse after completion of treatment; 3) increasing the effectiveness of pharmacotherapy; 4) the solution of psychosocial problems (which may either be a consequence of a mental disorder or precede its appearance); 5) elimination of the causes contributing to the development of psychopathology: changing maladaptive beliefs (schemes), correcting cognitive errors, changing dysfunctional behavior.

To achieve these goals, a cognitive psychotherapist helps the client to solve the following tasks: 1) to realize the influence of thoughts on emotions and behavior; 2) learn to identify negative automatic thoughts and observe them; 3) explore negative automatic thoughts and arguments that support and refute them (“for” and “against”); 4) replace erroneous cognitions with more rational thoughts; 5) discover and change maladaptive beliefs that form a fertile ground for the emergence of cognitive errors.

Of these tasks, the first, as a rule, is solved already during the first (diagnostic) session. To solve the remaining four problems, special techniques are used, the description of the most popular of them is given below.

Methodology and features of cognitive psychotherapy

Today, CT is at the crossroads of cognitivism, behaviorism and psychoanalysis. As a rule, textbooks published in recent years in Russian do not address the issue of the existence of differences between the two most influential variants of cognitive therapy - A. Beck's CT and A. Ellis' REBT. An exception is the monograph by G. Kassinov and R. Tafreit with a preface by Albert Ellis.

As the founder of Rational Emotive Behavioral Therapy (REBT/REBT), the first cognitive behavioral therapy… I was naturally drawn to chapters 13 and 14 of this book. Chapter 13 describes Aaron Beck's cognitive therapy methods, while Chapter 14 introduces some of the main REBT methods. … Both chapters are well written and cover many of the similarities as well as the major differences between the two approaches. … But I would also like to point out that the REBT approach definitely emphasizes emotional-memory-(evocative-)experiential ways more than cognitive therapy.

Foreword / A. Ellis // Kassinov G., Tafreyt R. Ch. Psychotherapy of anger. - M.: AST; St. Petersburg: Owl, 2006. - S. 13.

Although this approach may seem similar to cognitive therapy Beck, there are significant differences. In the REBT model, the initial perception of the stimulus and automatic thoughts is neither discussed nor questioned. ... The therapist does not discuss validity, but finds out how the client evaluates the stimulus. Thus, in REBT, the main emphasis is on ... assessing the stimulus.

Kassinov G., Tafreyt R. Ch. Psychotherapy of anger. - M.: AST; St. Petersburg: Owl, 2006. - S. 328.

Features of CT:

1. Natural science foundation: the presence of its own psychological theory of normal development and factors of the occurrence of mental pathology.
2. Target orientation and manufacturability: for each nosological group there is a psychological model that describes the specifics of disorders; accordingly, the “targets of psychotherapy”, its stages and techniques are highlighted.
3. Short-term and economical approach (unlike, for example, psychoanalysis): from 20-30 sessions.
4. The presence of an integrating potential inherent in the theoretical schemes of CT (both an existential-humanistic orientation, and object relations and behavioral training, etc.).

Basic theoretical provisions

1. The way an individual structures situations determines his behavior and feelings. Thus, in the center is the subject's interpretation of external events, which is implemented according to the following scheme: external events (stimuli) → cognitive system → interpretation (thoughts) → affect (or behavior). If interpretations and external events diverge greatly, this leads to mental pathology.
2. An affective pathology is a severe exaggeration of a normal emotion, resulting from a misinterpretation under the influence of many factors (see point # 3). The central factor is "private possessions (personal space)" ( personal domain), which is centered on the Ego: emotional disturbances depend on whether a person perceives events as enriching, as debilitating, as threatening or as encroaching on his possessions. Examples:
   • Sadness arises as a result of the loss of something valuable, that is, the deprivation of private property.
   • Euphoria is the sensation or expectation of acquisition.
   • Anxiety is a threat to physiological or psychological well-being.
   • Anger results from a feeling of direct attack (whether intentional or unintentional) or a violation of the laws, morals, or standards of the individual.
3. individual differences. They depend on past traumatic experiences (for example, the situation long stay in a confined space) and biological predisposition (constitutional factor). E. T. Sokolova proposed the concept differential diagnosis and psychotherapy of two types of depression, based on the integration of CT and psychoanalytic object relations theory:
   • Perfectionist melancholy(occurs in the so-called "autonomous personality", according to Beck). It is provoked by the frustration of the need for self-affirmation, achievement, autonomy. Consequence: the development of the compensatory structure of the "Grand Self". Thus, here we are talking about a narcissistic personality organization. The strategy of psychotherapeutic work: "containment" (careful attitude to heightened self-esteem, wounded pride and a sense of shame).
   • Anaclitic depression(occurs in the so-called "sociotropic personality", according to Beck). Associated with emotional deprivation. Consequence: unstable patterns of interpersonal relationships, where emotional avoidance, isolation and "emotional dullness" are replaced by overdependence and emotional attachment to the Other. The strategy of psychotherapeutic work: "holding" (emotional "up-nourishment").
4. The normal activity of the cognitive organization is inhibited under the influence of stress. There are extremist judgments, problematic thinking, concentration of attention is disturbed, and so on.
5. Psychopathological syndromes (depression, anxiety disorders, etc.) consist of hyperactive schemas with unique content that characterize a particular syndrome. Examples: depression - loss, anxiety disorder - threat or danger, etc.
6. Intense interaction with other people creates vicious circle maladaptive cognitions. A depressed wife, misinterpreting her husband’s frustration (“I don’t care, I don’t need her ...” instead of the real “I can’t help her in anything”), ascribes a negative meaning to her, continues to think negatively about herself and her relationship with her husband, moves away, and, as a consequence, her maladaptive cognitions are further strengthened.

Key Concepts

1. Scheme. These are cognitive formations that organize experience and behavior, it is a system of beliefs, deep worldview attitudes of a person in relation to himself and the world around him, influencing actual perception and categorization. Schemes can be:
   • adaptive / non-adaptive. An example of a maladaptive scheme: "all men are bastards" or "all women are bitches." Of course, such schemes are not true and are an overgeneralization, but such a position in life can cause damage, first of all, to the person himself, creating difficulties for him in communicating with the opposite sex, since subconsciously he will be negatively disposed in advance, and the interlocutor may understand and be offended.
   • positive/negative
   • idiosyncratic/universal. Example: depression - maladaptive, negative, idiosyncratic.
2. automatic thoughts. These are the thoughts that the brain writes to the "fast" memory area (the so-called "subconscious"), because they are often repeated or a person attaches special importance to them. In this case, the brain does not spend a lot of time re-thinking this thought slowly, but makes a decision instantly, based on the previous decision recorded in the "fast" memory. Such “automation” of thoughts can be useful when you need to quickly make a decision (for example, quickly pull your hand away from a hot frying pan), but it can be harmful when an incorrect or illogical thought is automated, so one of the tasks of cognitive psychotherapy is to recognize such automatic thoughts, return them from the area fast memory again into the area of ​​slow rethinking in order to remove incorrect judgments from the subconscious and overwrite them with correct counterarguments. Main characteristics of automatic thoughts:
   • reflexivity
   • Collapse and contraction
   • Not subject to conscious control
   • transience
   • Perseveration and stereotyping. Automatic thoughts are not the result of reflection or reasoning, they are subjectively perceived as justified, even if they seem ridiculous to others or contradict obvious facts. Example: “If I get a “good” mark in the exam, I will die, the world around me will collapse, after that I will not be able to do anything, I will finally become a complete nonentity”, “I ruined the lives of my children with a divorce”, “Everything that I I do, I do poorly.
3. cognitive errors. These are supervalent and affectively charged circuits that directly cause cognitive distortions. They are characteristic of all psychopathological syndromes. Kinds:
   • Arbitrary inferences- drawing conclusions in the absence of supporting facts or even in the presence of facts that contradict the conclusion.
   • Overgeneralization- conclusions based on a single episode, with their subsequent generalization.
   • Selective abstraction- focusing the attention of the individual on any details of the situation, ignoring all its other features.
   • Exaggeration and understatement- opposite assessments of oneself, situations and events. The subject exaggerates the complexity of the situation, while downplaying their ability to cope with it.
   • Personalization- the relation of the individual to external events as having a relation to him, when this is not actually the case.
   • Dichotomous thinking("black-and-white" thinking or maximalism) - attributing oneself or any event to one of two poles, positive or negative (in absolute terms). In a psychodynamic way, this phenomenon can be qualified as a protective mechanism of splitting, which indicates the "diffusion of self-identity".
   • duty- excessive focus on "I should" act or feel in a certain way, without evaluation real consequences such behavior or alternatives. Often arises from past imposed standards of behavior and patterns of thought.
   • prediction- the individual believes that he can accurately predict the future consequences of certain events, although he does not know or does not take into account all the factors, cannot correctly determine their influence.
   • mind reading- the individual believes that he knows exactly what other people think about this, although his assumptions do not always correspond to reality.
   • Labeling-associating oneself or others with certain patterns of behavior or negative types
4. Cognitive content(“themes”) corresponding to a particular type of psychopathology (see below).

Theory of psychopathology

Depression

Depression is an exaggerated and chronic experience of real or hypothetical loss. The cognitive triad of depression:

• Negative self-image: "I'm inferior, I'm a loser, at least!".
• Negative assessment of the surrounding world and external events: “The world is merciless to me! Why is this all happening to me?"
• Negative assessment of the future. “What is there to say? I just don't have a future!"

In addition: increased dependence, paralysis of will, suicidal thoughts, somatic symptom complex. On the basis of depressive schemas, corresponding automatic thoughts are formed and cognitive errors of almost all kinds take place. Themes:

• Fixation on real or imaginary loss (death of loved ones, collapse of relationships, loss of self-esteem, etc.)
• Negative attitude towards oneself and others, pessimistic assessment of the future
• Tyranny of duty

Anxiety-phobic disorders

Anxiety disorder is an exaggerated and chronic experience of real or hypothetical danger or threat. A phobia is an exaggerated and chronic experience of fear. Example: fear of losing control (for example, in front of your body, as in the case of fear of getting sick). Claustrophobia - fear of closed spaces; mechanism (and in agoraphobia): the fear that, in case of danger, help may not come in time. Themes:

• Anticipation of negative events in the future, the so-called. "anticipation of all sorts of misfortunes." In agoraphobia: fear of dying or going mad.
• The discrepancy between the level of claims and the conviction of one’s own incompetence (“I should get an excellent mark on the exam, but I’m a loser, I don’t know anything, I don’t understand anything”)
• Fear of losing support.
• A persistent notion of inevitable failure in an attempt to improve interpersonal relationships, to be humiliated, ridiculed or rejected.

perfectionism

The Phenomenology of Perfectionism. Main parameters:

• High standards
• Thinking in terms of "all or nothing" (either complete success or complete failure)
• Focus on failure

Perfectionism is very closely related to depression, but not the anaclitic depression (due to loss or loss), but the one associated with the frustration of the need for self-affirmation, achievement and autonomy (see above).

Psychotherapeutic relationships

The client and therapist must agree on what problem they are to work on. It is the solution of problems (!), Not change personal characteristics or deficiencies of the patient. The therapist must be very empathic, natural, congruent (principles taken from humanistic psychotherapy); should not be directive. Principles:

• The therapist and client collaborate in an experimental test of erroneous maladaptive thinking. Example: client: “When I walk down the street, everyone turns to me”, therapist: “Try to walk down the street normally and count how many people turned to you.” Usually such an automatic thought does not coincide with reality. The bottom line: there is a hypothesis, it must be tested empirically. However, sometimes the statements of psychiatric patients that on the street everyone turns around, looks and discusses them, still have a real factual basis - it's all about how the mentally ill looks and how he behaves at that moment. If a person talks quietly to himself, laughs for no reason, or vice versa, without looking away, looks at one point, does not look around at all, or looks around at others with fear, then such a person will certainly attract attention to himself. They will really turn around, look at and discuss it - simply because passers-by are interested in why he behaves this way. In this situation, the psychologist can help the client understand that the interest of others is caused by his own unusual behavior, and explain to the person how to behave in public so as not to attract undue attention.
• Socratic dialogue as a series of questions with the following objectives:
  1. Clarify or identify problems
  2. Help identify thoughts, images, sensations
  3. Explore the meaning of events for the patient
  4. Assess the consequences of persisting maladaptive thoughts and behaviors.
• Directed Cognition: The therapist-guide encourages patients to look at facts, evaluate probabilities, gather information, and put it all to the test.

Techniques and methods of cognitive psychotherapy

CT in the Beck version is a structured training, experiment, training in the mental and behavioral plans, designed to help the patient master the following operations:

• Reveal your negative automatic thoughts.
• Find the connection between knowledge, affects and behavior.
• Find facts for and against automatic thoughts.
• Look for more realistic interpretations for them.
• Learn to identify and change disruptive beliefs that lead to distortion of skills and experience.

Specific methods for identifying and correcting automatic thoughts:

1. Writing down thoughts. The psychologist may ask the client to write down on paper what thoughts come into his head when he tries to do desired action(or not to do an unnecessary action). It is advisable to write down thoughts that come to mind at the time of making a decision strictly in the order of their priority (this order is important because it will indicate the weight and importance of these motives in making a decision).
2. Thought diary. Many CT specialists suggest that their clients jot down their thoughts in a diary for several days to understand what the person thinks about most often, how much time they spend on it, and how much. powerful emotions experiences from his thoughts. For example, the American psychologist Matthew McKay recommended that his clients break the page in the diary into three columns, where they briefly indicate the thought itself, the hours of time spent on it, and evaluate their emotions on a 100-point scale in the range between: “very pleasant / interesting” - “ indifferent” - “very unpleasant/depressing”. The value of such a diary is also in the fact that sometimes even the client himself cannot always accurately indicate the reason for his experiences, then the diary helps both him and his psychologist to find out what thoughts affect his well-being during the day.
3. estrangement. The essence of this stage is that the patient must take an objective position in relation to his own thoughts, that is, move away from them. Suspension has 3 components:
   • awareness of the automaticity of a “bad” thought, its spontaneity, understanding that this scheme arose earlier under other circumstances or was imposed by other people from the outside;
   • the realization that a "bad" thought is maladaptive, that is, it causes suffering, fear or frustration;
   • the emergence of doubts about the truth of this non-adaptive thought, the understanding that this scheme does not correspond to new requirements or a new situation (for example, the thought “To be happy means to be the first in everything”, formed by an excellent student at school, can lead to disappointment if he does not manages to become the first in the university).
4. empirical verification("experiments"). Ways:
   • Find arguments for and against automatic thoughts. It is also advisable to put these arguments on paper so that the patient can re-read it whenever these thoughts come to him again. If a person does this often, then gradually the brain will remember the “correct” arguments and remove “wrong” motives and decisions from quick memory.
   • Weigh the advantages and disadvantages of each option. It is also necessary to take into account the long-term perspective, and not just the immediate benefit (for example, in the long term, problems from drugs will many times exceed temporary pleasure).
   • Construction of an experiment to test the judgment.
   • Conversation with witnesses of past events. This is especially true in those mental disorders where memory is sometimes distorted and replaced by fantasies (for example, in schizophrenia) or if the delusion is caused by a misinterpretation of the motives of another person.
   • The therapist refers to his experience, to fiction and academic literature, statistics.
   • The therapist incriminates: points out logical errors and contradictions in the patient's judgments.
5. Revaluation methodology. Checking the likelihood of alternative causes of an event.
6. decentration. With social phobia, patients feel in the center of everyone's attention and suffer from this. Here, too, an empirical test of these automatic thoughts is needed.
7. self-expression. Depressive, anxious, etc. patients often think that their ailments are controlled by higher levels of consciousness, constantly observing themselves, they understand that the symptoms do not depend on anything, and attacks have a beginning and an end. Conscious self-observation.
8. decatastrophic. At anxiety disorders. Therapist: “Let's see what would happen if…”, “How long will you experience such negative feelings?”, “What will happen next? You will die? Will the world collapse? Will it ruin your career? Will your loved ones abandon you?" etc. The patient understands that everything has a time frame, and the automatic thought “this horror will never end” disappears.
9. Purposeful repetition. Re-enactment of the desired behavior, repeated testing of various positive instructions in practice, which leads to increased self-efficacy. Sometimes the patient quite agrees with the correct arguments during psychotherapy, but quickly forgets them after the session and returns to the previous "wrong" arguments, because they are repeatedly recorded in his memory, although he understands their illogicality. In this case, it is better to write down the correct arguments on paper and reread them regularly.
10. Use of the imagination. Anxious patients are dominated not so much by "automatic thoughts" as by "obsessive images", that is, it is rather not thinking that maladjusts, but imagination (fantasy). Kinds:
    • Termination Technique: Loudly commanding yourself to “stop!” - the negative way of thinking or imagining stops. It also happens to be effective in stopping intrusive thoughts in some mental illnesses.
    • Repetition technique: repeat several times correct image thinking to break the stereotype.
    • Metaphors, parables, poems: The psychologist uses such examples to make the explanation clearer.
    • Modifying imagination: the patient actively and gradually changes the image from negative to more neutral and even positive, thereby understanding the possibilities of his self-awareness and conscious control. Usually, even after a bad setback, you can find at least something positive in what happened (for example, “I learned a good lesson”) and concentrate on it.
    • Positive imagination: a positive image replaces a negative one and has a relaxing effect.
    • Constructive imagination (desensitization): the patient ranks the probability of the expected event, which leads to the fact that the forecast loses its globality and inevitability.
11. Change of world view. Often the cause of depression is unfulfilled desires or excessively high demands. In this case, the psychologist can help the client weigh the cost of achieving the goal and the cost of the problem, and decide whether it is worth fighting further or whether it would be wiser to refuse to achieve this goal altogether, discard an unfulfilled desire, reduce requests, set yourself, for starters, more realistic goals, try to get more comfortable with what you have or find something to replace it. This is relevant in cases where the cost of not solving the problem is lower than suffering from the problem itself. However, in other cases, it may be better to work hard and solve the problem, especially if delaying the decision only aggravates the situation and causes more suffering for the person.
12. Replacement of emotions. Sometimes the client needs to come to terms with their past negative experiences and change their emotions to more adequate ones. For example, it may sometimes be better for a victim of a crime not to replay the details of what happened in her memory, but to say to herself: “It’s very unfortunate that this happened to me, but I will not let my abusers ruin the rest of my life for me, I will live in the present and the future, rather than constantly looking back at the past." You should replace the emotions of resentment, anger and hatred with softer and more adequate ones that will allow you to build your future life more comfortably.
13. Role reversal. Ask the client to imagine that he is trying to comfort a friend who finds himself in a similar situation. What could be said to him? What to advise? What advice would your loved one give you in this situation?
14. Action plan for the future. The client and therapist jointly develop for the client a realistic "action plan" for the future, with specific conditions, actions and deadlines, write this plan down on paper. For example, if a catastrophic event happens, then the client will perform some sequence of actions at the time indicated for this, and before this event happens, the client will not torment himself with needless worries.
15. Identifying Alternative Causes of Behavior. If all the "correct" arguments are stated, and the client agrees with them, but continues to think or act in a clearly illogical way, then you should look for alternative reasons for this behavior, which the client himself does not suspect or prefers to remain silent. For example, with obsessive thoughts, the process of deliberation itself often brings a person great satisfaction and relief, since it allows him to at least mentally imagine himself a "hero" or "savior", solve all problems in fantasies, punish enemies in dreams, correct his mistakes in a fictional world, etc. .d. Therefore, a person scrolls such thoughts over and over again not for the sake of a real solution, but for the very process of thinking and satisfaction, gradually this process drags a person deeper and deeper like a kind of drug, although a person understands the unreality and illogicality of such thinking. In particular severe cases, irrational and illogical behavior can even be a sign of serious mental illness(for example, obsessive-compulsive disorder or schizophrenia), then psychotherapy alone may not be enough, and the client also needs the help of drugs to control thinking (i.e., requires the intervention of a psychiatrist).

There are specific CT methods that are used only for certain types severe mental disorders, in addition to drug treatment:

• With schizophrenia, patients sometimes begin to engage in mental dialogues with imaginary images of people or otherworldly beings (the so-called "voices"). The psychologist, in this case, may try to explain to the schizophrenic that he is not talking with real people or creatures, but with the artistic images of these creatures he created, thinking in turn for himself, then for this character. Gradually, the brain "automates" this process and begins to issue phrases that are suitable for a fictional character in a given situation automatically, even without a conscious request. You can try to explain to the client that conversations with fictional characters normal people they also sometimes lead, but consciously, when they want to predict the reaction of another person to a certain event. Writers and directors, for example, even write entire books like this, thinking in turn for several characters at once. However, at the same time, a normal person is well aware that this image is fictional, so he is not afraid of him and does not treat him like a real being. Brain healthy people does not give interest and importance to such characters, therefore, does not automate fictional conversations with them. It's like the difference between a photograph and a living person: you can safely put a photo on the table and forget about it, because it doesn't matter, and if it were a living person, then they wouldn't do this to him. When the schizophrenic realizes that his character is just a figment of his imagination, he will also begin to deal with him much easier and stop getting this image from memory when not needed.

• Also, with schizophrenia, the patient sometimes begins to repeatedly mentally scroll through a fantasy image or plot, gradually such fantasies are deeply recorded in memory, enriched with realistic details and become very believable. However, this is the danger that the schizophrenic begins to confuse the memory of his fantasies with real memory and may, because of this, begin to behave inappropriately, so the psychologist can try to restore real facts or events using external reliable sources: documents, people who the patient trusts scientific literature, speaking with witnesses, photographs, videos, building an experiment to test a judgment, etc.

• In obsessive-compulsive disorder, it may be helpful for the patient to repeat counter-arguments about how he is being harmed several times during the occurrence of any obsessive thought. intrusive thoughts how he wastes his precious time on them, that he has more important things to do, that obsessive dreams become a kind of drug for him, scatter his attention and impair his memory, that these obsessions can cause ridicule from others, lead to problems in the family, on work, etc. As mentioned above, it is better to write down such useful counterarguments on paper so that you can reread them regularly and try to memorize them.

Effectiveness of Cognitive Psychotherapy

Factors in the Effectiveness of Cognitive Therapy:

1. Personality of the psychotherapist: naturalness, empathy, congruence. The therapist must be able to receive feedback from the patient. Since CT is a fairly directive (in a certain sense of the word) and structured process, as soon as a good therapist feels the dullness and impersonality of therapy (“solving problems according to formal logic”), he is not afraid of self-disclosure, he is not afraid of using imagination, parables, metaphors, etc. P.
2. The right psychotherapeutic relationship. Accounting for the patient's automatic thoughts about the therapist and the proposed tasks. Example: The patient's automatic thought: "I will make entries in my diary - in five days I will become the happiest person in the world, all problems and symptoms will disappear, I will begin to live for real." Therapist: “The diary is just a separate help, there will be no instant effects; your diary entries are mini-experiments that give you new information about yourself and your problems.”
3. Qualitative application of methods, an informal approach to the CT process. Techniques must be applied according to the specific situation, a formal approach drastically reduces the effectiveness of CT and can often generate new automatic thoughts or frustrate the patient. Systematic. Feedback accounting.
4. Real problems - real effects. Effectiveness is reduced if the therapist and the client do whatever they want, ignoring the real problems.

Cognitive Behavioral Therapy was born out of two popular methods in psychotherapy in the second half of the 20th century. These are cognitive (thought change) and behavioral (behavior modification) therapy. Today, CBT is one of the most studied therapies in this field of medicine, has undergone many official trials and is actively used by doctors around the world.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a popular form of treatment in psychotherapy based on the correction of thoughts, feelings, emotions, and behaviors to improve the patient's quality of life and rid them of addictions or psychological disorders.

IN modern psychotherapy CBT is used to treat neurosis, phobias, depression and other mental problems. And also - to get rid of any type of addiction, including drugs.

CBT is based on simple principle. Any situation first forms a thought, then comes an emotional experience, which results in a specific behavior. If the behavior is negative (for example, taking psychotropic drugs), then you can change it if you change the way of thinking and the emotional attitude of a person to the situation that caused such a detrimental reaction.

Cognitive Behavioral Therapy is relatively short technique, usually it lasts 12-14 weeks. Such treatment is used at the stage of rehabilitation therapy, when intoxication of the body has already been carried out, the patient has received the necessary drug treatment, and there comes a period of work with a psychotherapist.

The essence of the method

From a CBT perspective, drug addiction consists of a number of specific behaviors:

• imitation (“friends smoked / sniffed / injected, and I want to”) - actual modeling;
• based on personal positive experience from taking drugs (euphoria, avoiding pain, increasing self-esteem, etc.) - operant conditioning;
• coming from the desire to experience pleasant sensations and emotions again - classical conditioning.

Scheme of impact on the patient during treatment

In addition, a person’s thoughts and emotions can be affected by a number of conditions that “fix” addiction:

• social (conflicts with parents, friends, etc.);
• the influence of the environment (TV, books, etc.);
• emotional (depression, neurosis, desire to relieve stress);
• cognitive (the desire to get rid of negative thoughts, etc.);
• physiological (unbearable pain, "breaking", etc.).

When working with a patient, it is very important to determine the group of prerequisites that affected him specifically. If you form other psychological attitudes, teach a person to react to the same situations in a different way, you can get rid of drug addiction.

CBT always begins with the establishment of contact between the doctor and the patient and the functional analysis of dependence. The doctor must determine what exactly makes a person turn to drugs in order to work with these reasons in the future.

Then you need to set triggers - these are conditioned signals that a person associates with drugs. They can be external (friends, dealers, the specific place where the consumption takes place, the time - Friday night for stress relief, etc.). As well as internal (anger, boredom, excitement, fatigue).

They are used to identify special exercise- the patient should write down his thoughts and emotions in the following table for several days, indicating the date and date:

Subsequently, apply various techniques development of personal skills and interpersonal relationships. The former include stress and anger management techniques, various ways to take up leisure time, etc. Teaching interpersonal relationships helps to resist the pressure of acquaintances (an offer to use a drug), teaches you to deal with criticism, re-interact with people, etc.

The technique of understanding and overcoming drug hunger is also used, the skills of refusing drugs and preventing relapse are being developed.

Indications and stages of CPT

Cognitive-behavioral therapy has long been successfully used all over the world, it is an almost universal technique that can help in overcoming various life difficulties. Therefore, most psychotherapists are convinced that such treatment is suitable for absolutely everyone.

However, for treatment with CBT there are essential condition– the patient must himself realize that he suffers from a harmful addiction, and make a decision to fight drug addiction on his own. For people who are prone to introspection, accustomed to monitoring their thoughts and feelings, such therapy will have the greatest effect.

IN individual cases before the start of CBT, it is required to develop skills and techniques for overcoming difficult life situations (if a person is not used to coping with difficulties on his own). This will improve the quality of future treatment.

There are many different methods within the framework of cognitive behavioral therapy - in various clinics special techniques may be used.

Any CBT always consists of three consecutive stages:

1. Logical analysis. Here the patient analyzes his own thoughts and feelings, mistakes are revealed that lead to an incorrect assessment of the situation and incorrect behavior. That is, the use of illegal drugs.
2. empirical analysis. The patient learns to distinguish objective reality from perceived reality, analyzes his own thoughts and behaviors in accordance with objective reality.
3. pragmatic analysis. The patient determines alternative ways of responding to the situation, learns to form new attitudes and use them in life.

Efficiency

The uniqueness of the methods of cognitive-behavioral therapy is that they involve the most active participation of the patient himself, continuous introspection, and his own (and not imposed from the outside) work on mistakes. CBT can take many forms - individual, alone with the doctor, and group - perfectly combined with the use of medications.

In the process of working to get rid of drug addiction, CBT leads to the following effects:

• provides a stable psychological state;
• eliminates (or significantly reduces) the signs of a psychological disorder;
• significantly increases the benefits of drug treatment;
• improves the social adaptation of a former drug addict;
• reduces the risk of breakdowns in the future.

As studies have shown, best results CBT shows in treatment. Methods of cognitive-behavioral therapy are also widely used in getting rid of cocaine addiction.