Behavioral therapy: exercises and methods. Main tasks, methods of cognitive psychology

Principles of Cognitive Therapy Cognitive therapy is based on the ever-evolving formulation of the therapeutic case in terms of cognitive therapy. The therapist seeks to comprehend the patient's difficulties in three time frames. To begin with, he reveals what his current thinking is, which causes sadness and longing. The therapist then identifies the predisposing factors that influence the patient's perception and contribute to depression. Next, the therapist formulates a hypothesis about the formative events and the patient's persistent ways of interpreting those events that may have led to the onset of the depression.

Cognitive therapy requires building a strong therapeutic alliance. Cognitive therapy emphasizes cooperation and active participation. Cognitive therapy is goal-oriented and problem-focused. In the first session, the therapist asks the patient to list his problems and determine the goals of therapy that he would like to achieve. In cognitive therapy, the focus is on the present, especially at the beginning of treatment. In most cases, the treatment process should be clearly fixed on the current problems and specific situations that put the patient out of action.

Cognitive therapy is an educational therapy that aims to teach the patient to be their own therapist. In cognitive therapy Special attention focused on relapse prevention. At the very first session, the therapist explains to the patient the nature and course of his disorder, explains the essence of the process of cognitive therapy and introduces the cognitive model (shows how thoughts affect his emotions and behavior). Cognitive therapy is limited in time. In the process of cognitive therapy sessions are structured. Regardless of the diagnosis and stage of treatment, the cognitive therapist strives to strictly adhere to a specific plan in each session.

Cognitive therapy teaches patients to recognize and evaluate their dysfunctional attitudes and beliefs and find adaptive responses to them. Cognitive therapy techniques aim to change the patient's thinking, mood, and behavior.

Some techniques used in CBT Guided opening to allow the patient to recognize stereotyped dysfunctional patterns of interpretation; (the desire to arouse the patient's interest in finding beliefs and their causes and in establishing the role of traumatic events. The patient's imagination must be involved. Otherwise, psychotherapy can be reduced to a repetitive process that becomes more and more tedious over time. Varying the way of setting hypotheses, using different phrases and words, as well as metaphors and examples to illustrate their point of view, help the therapist and the patient to learn more useful from their relationship).

Examination of the peculiarity of the experience, since these patients often interpret their experiences in an unusual or exaggerated manner; Pointing out inaccurate conclusions or distortions to make the patient aware of his bias or the unreasonableness of certain automatic thought patterns; Joint empirical findings - work with the patient to test the validity of his beliefs, interpretations and expectations; Exploring explanations for other people's behavior;

Scaling - translating exaggerated interpretations into measurable quantities to counteract conventional dichotomous thinking; Reattribution - redistribution of responsibility for actions and results; Deliberate exaggeration - reducing thought to an extreme, which simplifies the situation and facilitates the reassessment of a dysfunctional conclusion;

Examining the advantages and disadvantages of maintaining or changing beliefs or behaviors and elucidating primary and secondary benefits; Overcoming the catastrophic nature of the patient's thoughts is enabling the patient, firstly, to realize his tendency to always expect the worst outcome and, secondly, to resist this tendency.

Working with schemas Schemas are cognitive formations that organize experience and behavior; they are 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, however, such a life position 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 (peculiarly painful, limited) / universal. Example: depression - maladaptive, negative, idiosyncratic.

We will call the first version of working with schemas "schematic restructuring". It can be likened to the reconstruction of a city. When it was concluded that separate structure or a complex of structures are broken, a decision is made to gradually destroy the old structures and build new ones in their place. This has been the goal of many psychotherapeutic approaches for many years (especially in psychoanalysis and the dynamic derivatives of the psychodynamic schools). But not all dysfunctional schemas can be restructured, nor is it always justified given the time, energy, or skills available to the patient or therapist.

An example of a complete schematic restructuring is the transformation of a person with a paranoid personality disorder into a completely trusting person. Concrete schemes regarding the potential and imminent danger of other people must be eliminated, to be replaced by beliefs about the reliability of people, the low probability of attack and harm, and the belief that there will always be people ready to offer help and support. Obviously, this treatment option is the most laborious and time consuming, and a compromise must be reached between overly active schemes, corresponding to mistrust, and more benevolent schemes. In other words, restructuring consists in weakening dysfunctional schemas and developing more adaptive ones.

Many patients have never formed adequate schemas to accept experiences that conflict with their dysfunctional core beliefs. Consequently, they are unable to integrate new positive experiences and thus continue to filter events through pre-existing schemas. As a result, their life experiences are shaped in a way that confirms the patients' dysfunctional (usually negative) beliefs about themselves and other people. In more difficult patients, especially those with borderline personality disorder, there may be areas where adaptive schemas are simply not available. Therefore, they must create adaptive structures in order to gain new constructive experiences.

A variety of methods can be used to build new schemes or strengthen broken ones. For example, the creative use of diaries for orderly recording and storing new observations. A person who has the belief "I am inadequate" may have notebook with several sections: "work", "social contacts", "household duties", "leisure". Small examples of adequacy should be noted daily in each section. The therapist can help the patient identify examples of adequacy and ensure that they are recorded regularly. By reviewing these tapes, the patient helps himself to confront absolute negative beliefs when stressed or "failed" when the more familiar negative schema is activated.

The second possibility in the process of change is "schematic modification". This process involves relatively less change in the basic way of responding to the world than with reconstruction. A comparison with the restoration of an old house is appropriate here. As clinical example one might refer to the transformation of the corresponding paranoid personality schemas about trust into beliefs less related to mistrust and suspicion, and also attempts to stimulate the patient to trust some people in some situations and to evaluate the results.

The third possibility is "schematic reinterpretation". It is to help patients understand and reinterpret their lifestyle and schemas in a more functional way. For example, a hysterical personality may recognize the dysfunctional nature of the belief that it is necessary to be loved and adored by everyone, but continue to feel the love of people as a source of reward in some situations - for example, in communicating with their students. younger age. If the narcissistic personality wants to be wanted and respected by earning a title (for example, a professor or doctor), he can satisfy this desire for status without being guided by obsessive beliefs about the value of prestige.

Behavioral Methods There are three purposes for using behavioral methods. First, the psychotherapist may be faced with the need to work directly at modifying harmful behaviors. Second, patients may lack skills, and psychotherapy should include the building of these skills as a component. Third, behavioral tasks can be given to complete at home to help test cognitive structures.

The following behavioral methods Performance monitoring and planning are useful, which enable the retrospective identification and forward planning of changes; Planning for skill development and pleasure activities to increase personal effectiveness and confirm the success of changes in experience and the pleasure (or lack thereof) received from this; Behavioral training, modeling, self-confidence building and role-playing to develop skills before first attempts to respond more effectively to both old problem situations and new ones;

Behavioral methods of teaching relaxation and distraction, which are used when anxiety is threatened in the course of change Work in natural settings, when the therapist accompanies the client in a problem situation to help him work with dysfunctional schemas and actions that (for whatever reason) are not amenable to influence in a normal counseling situation; Staged tasking so that the patient can experience change as a progressively increasing process during which the difficulty of each component can be adjusted and mastery is gradually acquired.

Wolpe Systematic Desensitization Systematic desensitization psychotherapy is a form of behavioral psychotherapy that serves the purpose of reducing emotional receptivity to certain situations. Developed by Joseph Wolpe on the basis of I. P. Pavlov's experiments on classical conditioning. It is based on the assumption that during a phobia, affect is generalized and the emotional experience of fear is associated with the initially neutral signs of those situations in which fear was born. Because of this, a psychotherapeutic goal is formulated - to achieve the extinction of a conditioned reflex, which is the experience of fear to objectively neutral stimuli, by linking these stimuli with a pleasant reinforcement.

According to Wolpe, the inhibition of fear reactions has three stages; compiling a list of frightening situations or stimuli with an indication of their significance or hierarchy; training in any method of muscle relaxation in order to form the skill to create the physical state, opposite to the state with the emotion of fear, that is, the skill to inhibit the reaction of fear; gradual presentation of a frightening stimulus or situation in combination with the use of a muscle relaxation method. An example would be dealing with a traffic phobia. The patient is taught, for example, the method autogenic training. Then the patient is taught to imagine himself in the subway, keeping even breathing and relaxed muscles. Then the instructor can go down with him to the subway, helping to control breathing and muscle condition. Then the instructor can drive with the patient together one stop. The next day, the patient is invited to go down the subway alone, controlling breathing and muscle condition, the next day - to drive one stop, and so on until the fear reaction disappears.

Working with Automatic Thoughts The Nature of Automatic Thoughts You are constantly analyzing the world, attaching a label to every event or experience. You automatically interpret everything you see, hear, touch, feel. You rate events as good or bad, pleasant or painful, safe or risky. This process accompanies your whole life, giving each experience an individual meaning.

Estimates are born in the course of the endless dialogue that you have with yourself, arise from the stream of thoughts that falls into the back of your consciousness. These thoughts are fleeting, but significant enough to provoke the strongest emotions. Albert Ellis, a representative of the rational emotional direction of psychotherapy, called it an internal dialogue, and the theorist of cognitive psychotherapy Aaron Beck - automatic thoughts. Beck prefers the term "automatic thoughts" because it "describes more accurately the way these thoughts are experienced. A person perceives these thoughts as mechanical - arising without prior reflection and argumentation, and therefore they seem to him convincing and justified.

Automatic thoughts have the following characteristics: They are often shorthand, that is, they consist of only a few keywords or telegraph-style phrases: “lonely…tired…I can’t take this…cancer…nothing good.” One word or short phrase acts as a label for a group of painful memories, fears, reproaches to oneself. Often automatic thoughts do not need words at all. They arise in the form of a fleeting visual image, an imaginary sound or smell, any physical sensation. For example, one woman who is afraid of heights has an image of the floor tilting for a fraction of a second, and it seems to her that she is sliding down to the window. This instant illusion causes a feeling of extreme anxiety every time she rises above the fourth floor.

Sometimes automatic thoughts are a brief recreation of some past events. A depressed woman constantly sees the stairs from the department store where her husband first announced his intention to leave. One image of this staircase is enough for all the feelings associated with the loss to flood over it. Sometimes automatic thoughts take the form intuitive knowledge without words, images or sensory experiences. For example, one chef was so hampered by self-doubt that he did not even try to get promoted to take the place of a chef.

Automatic thoughts are undeniable, no matter how illogical they may be. For example, a man who reacted angrily to the death of his best friend, really believed for some time that a friend died on purpose, only to annoy him. Automatic thoughts have the same plausibility as immediate sensory experiences. Your automatic thoughts are as real to you as they are the world. If, upon seeing a man in a Porsche, you think: “He is rich and only cares about himself,” then for you this judgment will be as undeniable as the color of your shirt.

Automatic thoughts are perceived as spontaneous. You do not doubt the truth of automatic thoughts because they are automatic. They seem to arise spontaneously - due to ongoing events. They just suddenly appear, and you barely notice them, let alone subject them to logical analysis. Automatic thoughts often have the character of an obligation - must, must, should. A woman who recently lost her husband thinks, “You have to bear this alone. You shouldn't burden your friends." Every time that thought pops into her mind, a wave of despair sweeps over her. People torture themselves with all sorts of “shoulds”: “I should be happy. I need to be more energetic, creative, responsible, loving, generous…” Every hard “should” causes guilt and lower self-esteem.

Shoulds are difficult to destroy because they are adaptive in origin and purpose. These are simple life rules that have worked in the past. They are patterns of survival that you can quickly turn to when under stress. The problem is that these rules become such automatically, and you simply do not have time to analyze them. They are so fixed that you cannot adjust them to accommodate a changing situation.

Automatic thoughts often cast things in the worst possible light. They prophesy disaster, make you see danger in everything, set you up for the worst. Your stomach hurts - it means you have cancer, your loved one is not as attentive as before - it means that he has lost interest in you. Such thoughts are the main source of anxiety. But they are hard to give up because they help predict the future and prepare for the worst-case scenario.

Automatic thoughts are relatively unique. In a crowded theater hall, one woman stood up abruptly, slapped her companion, and quickly headed for the exit. Eyewitnesses of this incident reacted in different ways. Some spectator was frightened, because she thought: “He will suit her when they return home.” She clearly imagined the brutal beating and recalled being physically abused herself. The teenager got angry: “Poor fellow. He probably wanted to kiss her, and she humiliated him so. Here's a bitch! The middle-aged man became despondent, thinking: "It seems that he has lost her forever - he will never be able to get her back." As you can see, each reaction is based on a unique perception. this event and evokes completely different emotions.

Automatic thoughts are stable and spontaneous. They are difficult to "turn off" or change because they are unconscious and seem very convincing. They imperceptibly intersperse into the fabric of your internal dialogue and seem to appear and disappear of their own accord. One automatic thought serves as a signal for another, and so on. Surely you are familiar with this chain reaction when one depressing thought gives rise to a whole galaxy of depressive thoughts.

Automatic thoughts are often different from your public statements. Many people communicate with others in a completely different way than with themselves. To outsiders, the events of life are presented as having a logical causal relationship. But in the depths of one's own consciousness, these same events are seasoned with poison that detracts from human dignity, or gloomy forecasts.

For example, a manager calmly explains aloud: “Ever since I was fired, I have been in a somewhat depressed state.” This dry statement stands in stark contrast to his actual thoughts brought on by unemployment: “I am a loser. I will never be able to find a new job... My family will starve to death. I won't be able to do anything!" His internal monologue plunges him deeper and deeper into the tar barrel.

Automatic thoughts keep you stuck on the same issues. Persistent anger, anxiety, or depression is the result of predominating certain automatic thoughts in your head and not allowing any others. The main topic for reflection of people with increased anxiety is danger. They are consumed by her presentiment and are constantly in anticipation of pain. Depressed individuals are often past focused and obsessed with the topic of loss, they focus on their own failures and shortcomings. People who are constantly irritated tend to blame others for all their troubles.

By dwelling on the same problems, you notice only one side of what is happening and, as a result, cause constant painful experiences in yourself. Beck defined this narrowed field of vision as "selective abstraction", which means perceiving only certain aspects of the situation and ignoring all others.

Automatic thoughts are suggested. From childhood, you have been taught to think. Family, friends, the media have taught you to interpret events in a certain way. Behind long years automatic thoughts have settled in your head that are quite difficult to detect, let alone change. This is bad. However good news that it is still possible to change your perception of reality.

Choosing an automatic thought-target Focus on this automatic thought. (“How long have you had this idea?”, “What emotions do you experience when you think this way?”, “What do you do after this thought has visited you?”.) Find out more details about the situation in which the automatic thought. (“What were you told before you thought this?”, “When did this happen?”, “Where were you at that moment?”, “Tell me more about this incident.”) Find out how typical this automatic thought. (“Do such thoughts often visit you?”, “In what cases?”, “Do such thoughts bother you a lot?”)

Identify other automatic thoughts and figurative representations that arise in the same situation. (“What else did you think about?”, “What images did you draw for yourself or what mental pictures did you have?”) Start solving problems related to the situation in which automatic thought arises. ("What can you do in this situation?", "How did you get out of this situation before?", "What would you like to do?") Determine the belief that underlies this automatic thought. ("If this thought were true, what would it mean to you?") Move on to the next topic. ("Good. I think I understand you. Tell me, what else important happened last week?")

To select the most appropriate of the identified automatic thoughts, the therapist asks himself the following questions. What do I want to achieve in this session? Will working on this thought help achieve the therapeutic goals that I have outlined for this session? What has the patient set as the agenda? Will working with this thought touch upon an actual problem for him? If not, do we have enough time to consider the problem as well? disturbing patient? Will he cooperate with me in evaluating this thought?

Is this thought significant enough to dwell on it in more detail? Is it likely that it is significantly distorted or dysfunctional? Is it typical for the patient? Will working with this thought help the patient feel better in more than just this one situation? Can I improve the patient's conceptualization model?

Working with automatic thought. Before working on a particular automatic thought, the therapist determines whether the thought is really worthy of attention. He asks the patient the following questions. How much do you now trust this thought (0 100%)? What feelings and emotions do you have because of this thought? How intense are these emotions (0 100%)?

If the patient is firmly convinced of the truth of the dysfunctional automatic thought and strongly pronounced negative emotions, the therapist clarifies the big picture by asking the patient questions according to the cognitive model. When does this thought occur? In what situations exactly? Do other problematic thoughts and images (perceptions) visit you in the same situation? Does this thought give you any physical sensations? What do you do after you have this thought?

Once the therapist has a general idea of ​​a given automatic thought and the patient's associated responses, the therapist proceeds in one of the following ways. Aloud or mentally complements his model of the patient’s conceptualization (emphasizes how this thought fits into it): “Is this another example of how you constantly predict failure to yourself?” Strengthens the cognitive model using the example of a specific automatic thought (usually at the beginning of therapy ), for example: "So, when you were looking for a job, we had the thought:" I will never get a job. " Because of this, you were upset, stopped looking. Right?"

Through dialogue, encourages the patient to evaluate the dysfunctional thought and find an adaptive response to it: "What evidence is there that you will never get a job?" Together with the patient, he is looking for a solution to the problem: "What can you do to solve the problem?"

Uses the Falling Arrow Technique First, the therapist identifies the patient's typical automatic thoughts that arise from his dysfunctional belief. The therapist then asks the patient to assume that the automatic thought reflects the true state of affairs, and asks what this alignment means. Note that asking what an automatic thought means to a patient often helps to identify an intermediate belief; asking what this thought means to the patient himself usually helps to reveal a core belief. These are the questions the therapist asks the patient until one or more important beliefs are identified.

Cognitive therapy was proposed by L. Beck in the 60s of the XX century, primarily for the treatment of patients with depression. Subsequently, the indications for its use were expanded, and it began to be used to treat patients with phobias, obsessive disorders, psychosomatic illnesses, borderline disorders, as well as to help clients with psychological problems that do not have clinical symptoms.

Cognitive therapy does not share the views of the three main psychotherapeutic schools: psychoanalysis, which considers the source of disorders to be the unconscious; behavioral therapy, which emphasizes only obvious behavior; traditional neuropsychiatry, according to which the causes of emotional disorders are physiological or chemical disorders. Cognitive therapy is based on the rather obvious idea that a person's ideas and statements about himself, his attitudes, beliefs and ideals are informative and meaningful.

Cognitive therapy is an active, directive, time-limited structured approach used in the treatment of various psychiatric disorders(e.g. depression, anxiety, phobias, pain and etc.). This approach is based on the theoretical premise that a person's emotions and behavior are largely determined by how he structures the world. A person's ideas (verbal or figurative "events" present in his mind) are determined by his attitudes and mental constructions (schemes) formed as a result of past experience. For example, in human thinking interpreting any event in terms of its own competence or adequacy, such a scheme can dominate: "Until I achieve perfection in everything, I am a loser." This scheme determines his reaction to a variety of situations, even those that are in no way related to his competence (Beck A., Rush A., Sho B., Emery G., 2003).

Cognitive therapy proceeds from the following general theoretical provisions (see ibid.):

Perception and experience in general are active processes involving both objective and introspective data;

Representations and ideas are the result of a synthesis of internal and external stimuli;

The products of a person's cognitive activity (thoughts and images) make it possible to predict how he will evaluate this or that situation;

Thoughts and images form a "stream of consciousness", or a phenomenal field that reflects a person's ideas about himself, the world, his past and future;

Deformation of the content of basic cognitive structures causes negative changes in the emotional state and behavior of a person;

Psychological therapy can help the patient become aware of cognitive distortions;

By correcting these distorted dysfunctional constructs, the patient's condition can be improved.

In order to better understand depressive thinking disorders, A. Beck and co-authors note (Beck A., Rush A., Sho B., Emery G., 2003), it is useful to consider them from the point of view of the methods used by the individual to structure reality. If we divide the latter into "primitive" and "mature", then it is obvious that in depression a person structures experience in relatively primitive ways. His judgments about unpleasant events are global in nature.

The meanings and meanings presented in the stream of his consciousness have an exclusively negative connotation, they are categorical and evaluative in content, which gives rise to an extremely negative emotional reaction. In contrast to this primitive type of thinking, mature thinking easily integrates life situations into a multidimensional structure (and not into any one category) and evaluates them in quantitative rather than qualitative terms, correlates with each other, and not with absolute standards. Primitive thinking reduces the complexity, diversity and variability of human experience, reducing it to a few of the most general categories.

Personality is formed by "schemes", or cognitive structures, which are basic beliefs (positions). These schemas begin to be created in childhood on the basis of personal experience and identification with significant others. People develop concepts about themselves, about others, about how the world functions. These concepts are reinforced by further learning experience and, in turn, influence the formation of other beliefs, values ​​and positions (Aleksandrov A.A., 2004).

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

Patients with borderline personality disorders have what are called early negative schemas, early negative core beliefs. For example: “Something wrong is happening to me”, “People should support me and should not criticize, they should agree with me, understand me correctly.” In the presence of such beliefs, these people easily develop emotional disorders.

Another common belief was called "conditional assumption" by Beck. Such assumptions, or positions, begin with "if." Two conditional assumptions often noted in depressed patients: "If I don't succeed in everything I do, no one will respect me"; “If a person does not love me, then I am not worthy of love.” Such people may function relatively well until they experience a series of defeats or rejections. After that, they begin to believe that no one respects them or that they are unworthy of love.

A feature of cognitive therapy that distinguishes it from more traditional types, such as psychoanalysis and client-centered therapy, lies in the active position of the doctor and his constant desire to cooperate with the patient. A depressed patient comes to the appointment confused, distracted and immersed in his thoughts, and therefore the therapist must first help him organize his thinking and behavior - without this it is impossible to teach the patient to cope with the demands of everyday life. Due to the symptoms present at this stage, the patient is often uncooperative, and the therapist has to use resourcefulness and ingenuity to encourage him to actively participate in various therapeutic operations.

Classical psychoanalytic techniques and techniques, for example, the technique of free association, which implies a minimum of activity on the part of the therapist, are not applicable when working with depressed patients, as the patient is even more immersed in the quagmire of his negative thoughts and ideas.

Cognitive, emotional, and behavioral channels interact in therapeutic change, but cognitive therapy emphasizes the leading role of cognition in inducing and maintaining therapeutic change. Cognitive change occurs at three levels:

1) in arbitrary thinking;

2) in continuous or automatic thinking;

3) in assumptions (beliefs).

Each level has its own accessibility for analysis and stability.

The tasks of cognitive therapy include correcting erroneous processing of information and helping patients modify the beliefs that support their maladaptive behavior and emotions. Cognitive therapy initially aims to relieve the symptom, including problematic behavior and logical distortions, but the ultimate goal is to eliminate systematic biases in thinking.

To achieve this, the patient in the course of cognitive therapy must learn:

a) identify and modify their dysfunctional thoughts and behavior;

b) recognize and correct cognitive patterns that lead to dysfunctional thinking and behavior.

It is important to teach the patient to approach problems logically and to equip him with various techniques so that he can cope with these problems. In other words, the task of cognitive therapy is to help the patient develop certain skills, and not just neutralize his suffering. The patient learns:

a) realistically evaluate events and situations that are significant for him;

b) pay attention to different aspects of situations;

c) produce alternative explanations;

d) test their maladaptive assumptions and hypotheses by changing behavior and testing more adaptive ways of interacting with the outside world.

The long-term goal of cognitive therapy is to facilitate the process of psychological maturation, which involves honing acquired skills and developing an objective attitude to reality, including honing interpersonal skills and learning more effective methods of adapting to complex and diverse situations.

Cognitive therapy views the patient's beliefs as hypotheses that can be tested through behavioral experimentation. 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, he asks questions to extract information about the meaning, function, and consequences of the patient's beliefs, and then the patient himself decides whether to reject, modify, or retain his beliefs, having previously recognized their emotional and behavioral consequences.

Cognitive therapy is designed to teach patients (Aleksandrov A. A., 2004):

Control dysfunctional (irrational) automatic thoughts;

Be aware of the connections between cognitions, affects and behavior;

Explore the arguments for and against dysfunctional automatic thoughts;

Replace dysfunctional automatic thoughts with more realistic interpretations;

Identify and change beliefs that predispose to experience distortion.

To solve these problems, cognitive therapy uses cognitive and behavioral techniques.

Beck formulates three main strategies for cognitive therapy: collaboration empiricism, Socratic dialogue, and guided discovery.

FIRST INTERVIEW

Many therapists prefer to start the interview by asking, "How do you feel now, sitting here?" It is not uncommon for patients to respond that they are anxious or express pessimism. In this case, the therapist must carefully find out what thoughts are hidden behind these unpleasant feelings. The therapist might ask, "Do you remember what you thought about on the way here and sitting in the waiting room?" or "What were you expecting when you went to meet me?" Even by simply sharing his expectations with the therapist, the patient enters the path of therapeutic cooperation.

An example of the first interview is given by A. Beck and co-authors:

Therapist. How did you feel today when you walked here?

Patient. I was terribly nervous.

Therapist. Did you have any thoughts about me or upcoming therapy?

Patient. I was afraid you would think that I was not suitable for your therapy.

Therapist. What other thoughts and feelings did you have?

Patient. To be honest, I felt a bit hopeless. You see, I've already been to so many therapists, and my depression is still with me.

Therapist. Tell me, now, sitting here and talking to me, do you still think that I will refuse your treatment?

Patient. Well, I don't know... But you won't refuse?

Therapist. No, of course not. But using this idea of ​​yours as an example, you can see how negative expectations make you feel anxious. How do you feel now that you know you were wrong in your expectations?

Patient. I'm not as nervous as I used to be. But I still don't get scared. I'm afraid you won't be able to help me.

Therapist. I think a little later we will return to this feeling of yours and see if you still experience it. In any case, I think we have managed to trace one important pattern. We have established that negative ideas give rise to unpleasant feelings in a person - in your case, anxiety and a sense of hopelessness. How do you feel now?

Patient (relaxing a little). Better.

Therapist OK. Now, try to be as brief as possible about what I have to help you with.

Starting the interview in this way, the therapist solves several problems (Beck A. et al., 2003):

a) helps the patient to relax and involve him in the therapeutic relationship;

b) receives information about the negative expectations of the patient;

c) shows the patient how his thoughts affect his emotional state;

d) gives an incentive to the patient, who is convinced of the possibility of quickly neutralizing unpleasant feelings, to identify and correct his cognitive distortions.

A well-conducted interview, in addition to providing the therapist with diagnostic data, information about the patient's past and present life, his psychological problems, attitudes towards treatment and motivation, also allows the patient to look at his problems more objectively.

An example of a cognitive approach

A. Beck and co-authors (2003) cite as an example the most characteristic case, reflecting the typical reactions of a patient with a deep degree of depression to cognitive therapy. The treatment required 22 sessions, the entire course of therapy took 14 weeks (twice a week for 8 weeks; once a week for 6 weeks).

Patient X., 36 years old, housewife, has two sons (14 and 9 years old) and a daughter (7 years old). Married for 15 years. My husband is 37 years old and works as a sales manager in a car company. The patient described him as a "reliable" and "loving" person. She calls herself "insignificance", believes that "neither a good mother nor a normal wife" came out of her. It seems to the patient that she does not love her husband and children and is a "burden" for them; she admitted that she repeatedly had thoughts of suicide.

The therapy began with the justification of the cognitive approach and discussion of the patient's reactions to the presented model. To get acquainted with the general concepts, the patient was asked to read the brochure "How to beat depression". Therapy thereafter focused on existing symptoms of depression, initially on behavioral and motivational disturbances. When there were significant shifts in the patient's behavior and motivation, the therapist turned his attention to changing the content and patterns of thought.

First session. The patient came to the first session with the feeling that she was "on the verge of a breakdown." She was especially worried about the fact that she had lost her former love for her husband and children. She had suicidal thoughts, but after reading the pamphlet How to Conquer Depression, which, according to the patient, described "just like her case," she found some hope. The patient scolded herself for "selfishness" and "childish behavior", she was afraid that her husband would turn away from her, since she does not bring any benefit, doing only "nonsense" housework. During the session, she acknowledged that constant self-criticism negatively affects her well-being, but remarked at the same time: "The truth is always unpleasant." The therapist explained to the patient that she was experiencing depression and that her negative reactions may be one of the manifestations of the disease.

Second session. The patient, with tears in her eyes, declared that her marriage "will definitely end in divorce." She told the therapist how one day her husband, noticing positive changes in her mood, invited her to the movies. She refused, saying that she "does not deserve entertainment," and then she also blamed her husband for "squandering." The patient wondered why the husband "doesn't feel" how much he and the children annoyed her. She believed that his “insensitivity” indicated indifference to her (“And I don’t blame him for that”), and therefore came to the conclusion that a divorce was inevitable. The therapist pointed out to the patient her selective inattention to facts (in particular, the fact of inviting her to the movies) that refute her conclusions. This remark seemed to make some impression on the patient.

Third session. According to the diary entries, morning hours the patient devoted herself to housework, and in the afternoon either watched soap operas or cried. She scolded herself, repeating that she was "not of any use," that she was not doing "anything useful." The patient complained that the children did not obey her, that she had to work hard to get her eldest son out of bed in the morning. It was obvious that the latter problem was caused by the patient's unwillingness to give him at least some of the responsibility for her own behavior. After discussion with the therapist, the patient agreed that she should give up the habit of waking her son up in the morning. It was decided that she would tell him about the introduction of a "new rule" - from now on, everyone in their seven would decide for himself what time he should get up.

Other problems included a lack of psychological intimacy with her husband and an inability to finish what she started. Since the patient, according to the diary entries, remained quite active during the day, which indicated a quite acceptable level of motivation, therapeutic efforts were directed at changing cognitive patterns.

Fourth session. For 3 days, the patient described 12 unpleasant situations when she experienced melancholy, anger or guilt. In most cases, it was about her skirmishes with children, after which she had thoughts that she was a "useless" mother. She punished them for any prank, thus trying to prevent criticism from her husband, relatives or acquaintances, but, on the other hand, she spent a lot of time and effort to satisfy the needs and demands of the children. Her thoughts revolved around what she "needed" to do around the house. She tried to be active, wanting to please her husband, although she believed that she "did not deserve" his good attitude. The therapist managed to shake the patient's self-critical attitude by saying that she should not blame herself for incompetence, but diversify her arsenal of educational measures. The patient was skeptical about this proposal, but after discussion showed some interest.

Fifth session. All the patient's thoughts revolved around the fact that she was not fulfilling her "marital duties" - from cleaning the house to sexual intimacy with her husband. The patient was convinced that her husband would certainly leave her if she did not "fix" her depression. The therapist explained that instant "reprisal" was impossible, that only a thorough examination of her own thinking and thorough introspection would help her overcome depression. It is curious that this remark of the therapist caused a clear relief in the patient. In the depths of her soul, she "knew" that she could not be reborn overnight, but in order to please her husband's expectations, she made increased demands on herself. During the session, the patient complained of sleep disturbances (it was difficult for her to fall asleep in the evenings). These disturbances appear to have been the result of the patient's constant berating of herself for her lack of sexual attraction and "loss of love" for her husband.

Sixth, seventh and eighth sessions. During these three sessions, the therapist tried to find out what demands the patient made on herself. In past sessions, the patient was able to understand that her self-flagellation and a sense of hopelessness are directly due to the constant comparison of herself with the ideal image of a mother, wife, person. The patient went over in her mind all the mistakes she had once made, while ignoring her achievements. Such extreme selectivity was also manifested in the way she perceived and interpreted her husband's behavior. The therapist talked to her husband and found out that he repeatedly tried to show his wife his love and affection, but in doing so only caused her to cry and feel guilty. After discussing concrete facts, the patient began to realize that her negative ideas did not reflect, but perverted reality and therefore needed to be rethought.

It took a lot of work for the therapist to push the patient towards setting more or less realistic goals. The patient was inclined to operate with global categories and saw her task in becoming a “good mother”, “a good wife”, without specifying what meaning she puts into these concepts. When the therapist led her to the need for behavior change, in particular suggesting that she tell her husband about her desires, for example, about the desire to transfer part of the household duties to him, her first reaction was: “I can’t.” However, in the course of role-playing, she was surprised to find that she could change her behavior. Initially, she enjoyed it, but subsequently, as expected, she began to devalue her achievements ("Just think! What's special about this?"). As she succeeded once again, she began to think about other "unsolvable" problems.

The therapist drew the patient's attention to this "no-win" cognitive attitude and spent considerable time discussing the defeatist nature of her thinking.

The patient realized, in particular, that she first severely criticized herself for her ineptitude, and then, having achieved success in something, began to scold herself for not having previously shown due diligence. Awareness of cognitive errors led to a reduction in depressive symptoms. Her loved ones noted that she became more determined and self-confident, and this observation strengthened her efforts. The other side of the coin was that the patient began to experience anxiety when her husband positively assessed the changes taking place with her, which did not decrease at this stage of therapy.

Control sessions: 1, 2, 3 months. During the control period, the patient showed no signs of depression. She herself noted with satisfaction that she had become more confident in herself. Together with her husband, she attended courses for parents. She had some problems in dealing with loved ones (husband, children, parents), especially when they began to make excessive demands. From time to time, old thought patterns came back to haunt her, but the patient learned that careful reassessment of the situation helps to counter automatic thoughts.

Cognitive Behavioral (Behavioral) Therapy(eng. Cognitive behavioral therapy) - psychotherapy, the essence of which is that the cause of psychological, personality, anxiety disorders (depression, phobias, fears, anxiety, stress disorders, psychopathization, etc.) is nothing more than internal, often unconscious, dysfunctional beliefs and attitudes of a person. (See Treatment for Psychiatric Disorders)

Principles of Cognitive Behavioral Therapy

These basic principles of cognitive therapy apply to every therapeutic case. However, the course of treatment can vary greatly according to the needs of each client, the nature of his problems, his goals, his ability and willingness to form a strong therapeutic alliance with the therapist, as well as his previous experience in psychotherapy and his treatment preferences.

Acceptance in cognitive behavioral therapy depends primarily on the characteristics of mental and emotional disorders of the client.

Principles of cognitive, behavioral psychotherapy:

1) Cognitive therapy is based on the ever-evolving formulation of the therapeutic case in its own terms.

2) Cognitive Behavioral Therapy requires a strong therapeutic alliance.

3) Particular importance is attached to cooperation and active participation.

4) She is goal-oriented and problem-focused.

5) Here the focus is on the present, especially at the beginning of psychotherapy.

6) This is an educational therapy, the purpose of which is to teach a person to be his own therapist. In cognitive therapy, special attention is paid to the prevention of relapse.

7) Cognitive therapy is limited in time. Most people suffering from depression and anxiety can be helped in 4-14 sessions.

8.) In the process of psychotherapy sessions are structured. Regardless of the diagnosis and stage of treatment, the cognitive therapist strives to strictly adhere to a specific plan in each session.

9) This therapy teaches people to recognize and evaluate their dysfunctional attitudes and beliefs and find adaptive responses to them.

10) Cognitive therapy techniques are aimed at changing the thinking, mood and behavior of a person.

While cognitive strategies such as Socratic dialogue or guided inquiry are the main tools of the cognitive psychotherapist, techniques borrowed from other areas of psychotherapy (especially behavioral therapy, Gestalt therapy, transactional analysis, and psychoanalytic therapy) are also widely used.

In choosing techniques for each case, the psychotherapist proceeds from the nature of the problem and his own goals in relation to specific psychotherapeutic sessions.

Cognitive, behavioral psychotherapy - the main goals

2) reducing the likelihood of relapse after the completion of psychotherapy;

3) increasing the effectiveness of pharmacotherapy;

4) solving psychosocial problems (which can either be a consequence of a mental, emotional disorder, or precede its appearance);

5) elimination of the causes contributing to the development of psychopathology: changing maladaptive beliefs, attitudes of a person, correcting cognitive errors, changing dysfunctional behavior.

Cognitive Behavioral Therapy - The tasks of the psychotherapist to help the client:

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.

Cognitive-behavioral psychotherapy with the inclusion of other techniques will help get rid of any psychological, personal and emotional problems

Cognitive behavioral therapy is a type of treatment that helps patients become aware of the feelings and thoughts that influence their behavior. It is commonly used to treat a wide range of ailments, including addiction, phobias, anxiety, and depression. Behavioral therapy, which is becoming very popular today, is mostly short-lived and is primarily aimed at helping people with a specific problem. In treatment, clients learn to change and identify disturbing or destructive thought patterns that have a negative impact on their behavior.

origins

How did cognitive or what made the adherents of popular psychoanalysis turn to the study of various models of cognition and human behavior?

Who founded in 1879 at the University of Leipzig the first official laboratory dedicated to psychological research, is considered the founder of experimental psychology. But it is worth noting that what was then considered experimental psychology is very far from today's experimental psychology. In addition, it is known that the current psychotherapy owes its appearance to the works of Sigmund Freud, known throughout the world.

At the same time, few people know that applied and experimental psychology have found fertile ground for their development in the United States. In fact, after the arrival of Sigmund Freud in 1911, psychoanalysis managed to surprise even prominent psychiatrists. So much so that in a few years, about 95% of the country's psychiatrists were trained in methods of working in psychoanalysis.

This monopoly in the United States on psychotherapy continued until the 1970s, while it lingered in the profile circles of the Old World for another 10 years. It is worth noting that the crisis of psychoanalysis is in terms of its ability to respond to various changes the demands of society after the Second World War, as well as the ability to "heal" it - began in the 1950s. At this time, alternative alternatives were born. The main role was played among them, of course, by cognitive behavioral therapy. Very few people dared to do exercises on their own from it then.

Arising immediately in different parts light, thanks to the contribution of psychoanalysts, dissatisfied with their tools of intervention and analysis, rational-emotional-behavioral therapy soon spread throughout Europe. It has established itself in a short time as a treatment method capable of providing an effective solution. various problems clients.

Fifty years have passed since the publication of J. B. Watson's work on the topic of behaviorism, as well as the application of behavioral therapy, only after that time did it take its place among the working areas of psychotherapy. But its further evolution took place at an accelerated pace. There was a simple reason for this: like other techniques that were based on scientific thought, cognitive behavioral therapy, the exercises of which are given in the article below, remained open to change, integrated and assimilated with other techniques.

She absorbed the results of research that was carried out in psychology, as well as in other scientific fields. This has led to the emergence of new forms of intervention and analysis.

This 1st generation therapy, characterized by a radical shift from the psychodynamic known therapy, was soon followed by a set of "innovations". They already took into account previously forgotten cognitive aspects. This fusion of cognitive and behavioral therapy is next generation behavioral therapy, also known as cognitive behavioral therapy. She is still being trained today.

Its development is still ongoing, more and more new methods of treatment are emerging, which belong to the therapy of the 3rd generation.

Cognitive Behavioral Therapy: The Basics

The basic concept suggests that our feelings and thoughts play a major role in shaping human behavior. So, a person who thinks too much about accidents on the runway, plane crashes and other air disasters may avoid traveling by various air transport. It is worth noting that the goal of this therapy is to teach patients that they cannot control every aspect of the world around them, while they can completely take control of their own interpretation of this world, as well as interaction with it.

In recent years, cognitive behavioral therapy has been used more and more on its own. This type treatment generally does not take much time, due to which it is considered more accessible than other types of therapy. Its effectiveness has been empirically proven: experts have found that it enables patients to cope with inappropriate behavior in its various manifestations.

Types of therapy

Representatives of the British Association of Cognitive and Behavioral Therapists note that this is a range of treatments based on principles and concepts created on the basis of patterns of human behavior and emotions. They include a huge range of approaches to getting rid of emotional disorders, as well as self-help opportunities.

The following types are regularly used by specialists:

• cognitive therapy;
• emotional-rational-behavioral therapy;
• multimodal therapy.

Behavior Therapy Methods

They are used in cognitive learning. Main Method This is behavioral rational-emotional therapy. Initially, the irrational thoughts of a person are established, then the reasons for the irrational belief system are found out, after which the goal is approached.

As a rule, general training methods are ways of solving problems. The main method is biofeedback training, which is used mainly to get rid of the effects of stress. In this case, an instrumental study of the general state takes place. muscle relaxation, as well as optical or acoustic feedback. Muscle relaxation with feedback is positively reinforced, after which it leads to complacency.

Cognitive Behavioral Therapy: Methods of Learning and Assimilation

Behavior therapy systematically uses the postulate of education, according to which it is possible to teach, as well as learn the right behavior. Learning by example is one of the most important processes. Methods of assimilation are guided mainly by operant conditioning, after which people build their desired behavior. A very important method is simulation learning.

The model is systematically imitated in vicarious learning - a person or a symbol. In other words, inheritance can be induced through participation, symbolically or implicitly.

Behavioral therapy is actively used when working with children. Exercise in this case contains reinforcing immediate stimuli, such as candy. In adults, this goal is served by a system of privileges, as well as rewards. Prompting (support of the therapist leading by example) is gradually reduced when successful.

Weaning methods

Odysseus in Homer's Odyssey, on the advice of Circe (the sorceress), orders himself to be tied to the mast of the ship in order not to be subjected to the singing of seductive sirens. He covered the ears of his companions with wax. With overt avoidance, behavioral therapy reduces the impact, while making some changes that increase the likelihood of success. For example, an aversive stimulus, such as a smell that causes vomiting, is added to negative behavior, alcohol abuse.

Cognitive behavioral therapy exercises are very different. So, with the help of a device designed for the treatment of enuresis, it turns out to get rid of nocturnal urinary incontinence - the mechanism of awakening the patient immediately works when the first drops of urine appear.

Elimination Methods

Elimination methods should deal with inappropriate behavior. It is worth noting that one of the main methods is systematic desensitization to decompose the fear response using 3 steps: training deep muscle relaxation, compiling a complete list of fears, and alternating irritation and relaxation of fears from the list in ascending order.

Methods of confrontation

These methods use accelerated contact with initial fear stimuli regarding peripheral or central phobias in various mental disorders. The main method is flooding (an assault with various stimuli using solid techniques). At the same time, the client is subjected to direct or intense mental influence of all kinds of fear stimuli.

Components of therapy

Often people experience feelings or thoughts that only reinforce them in a wrong opinion. These beliefs and opinions lead to problematic behaviors that can affect all areas of life, including romance, family, school, and work. For example, a person who suffers from low self-esteem may have negative thoughts about himself, his abilities, or his appearance. Because of this, a person will begin to avoid situations of interaction with people or refuse career opportunities.

Behavioral therapy is used to correct this. To combat such destructive thoughts and negative behaviors, the therapist begins by helping the client establish problematic beliefs. This stage, also known as "functional analysis", is important for understanding how situations, feelings and thoughts can contribute to the emergence inappropriate behavior. This process can be challenging, especially for clients who struggle with self-introspection tendencies, although it can lead to the conclusions and self-knowledge that are considered an essential part of the healing process.

Cognitive behavioral therapy includes the second part. It focuses on the actual behavior that contributes to the development of the problem. A person begins to practice and learn new skills, which can then be applied in real situations. Thus, a person who suffers from drug addiction is able to learn the skills to overcome this craving and can avoid social situations that could potentially cause a relapse, as well as cope with all of them.

CBT is, in most cases, a smooth process that helps a person take new steps towards changing their behavior. So, a sociophobe can start with a simple imagination of himself in a certain social situation which makes him anxious. Then he can try to talk to friends, acquaintances and family members. The process with regular movement towards the goal does not seem so difficult, while the goals themselves are absolutely achievable.

Use of CBT

This therapy is used to treat people who suffer from a wide range of diseases - phobias, anxiety, addiction and depression. CBT is considered one of the most studied types of therapy, in part because of the fact that treatment focuses on specific problems and its results are relatively easy to measure.

This therapy is best suited for introspective clients. For CBT to be truly effective, a person must be ready for it, they must be willing to put in the effort and time to analyze their own feelings and thoughts. This introspection can be difficult, but it is a great way to learn a lot more about the influence of internal state on behavior.

Cognitive Behavioral Therapy is also great for people who need a quick fix that doesn't involve the use of certain medications. So, one of the advantages of cognitive behavioral therapy is that it helps clients develop skills that can be useful today and later.

Development of self-confidence

It is worth mentioning right away that self-confidence comes from various qualities: the ability to express needs, feelings and thoughts, in addition, to perceive the needs and feelings of other people, the ability to say “no”; in addition, the ability to start, end and continue conversations, while speaking to the public freely, etc.

This training is aimed at overcoming possible social fears, as well as difficulties in contacts. Similar effects are also used for hyperactivity and aggressiveness, to activate clients who are long time in the treatment of psychiatrists, and with mental retardation.

This training primarily has two goals: the formation of social skills and the elimination of social phobias. Many techniques are used, for example, behavioral exercises and role-playing, training in daily situations, operant techniques, model learning, group therapy, video techniques, methods of self-control, etc. This means that in this training, in most cases, we are talking about a program using various methods in a certain sequence.

Behavioral therapy for children is also used. Special forms of this training were created for kids with communication difficulties and social phobias. Peterman and Peterman proposed a therapeutic compact program that, along with group and individual training, also includes counseling for the parents of these children.

Criticism of the CBT

Some patients at the beginning of treatment report that, regardless of the simple enough awareness of the irrationality of some thoughts, the mere awareness of the process of getting rid of it does not make it easy. It should be noted that behavioral therapy involves identifying these thought patterns, and it also aims to help get rid of these thoughts using a huge number of strategies. They may include role play, journaling, distraction and relaxation techniques.

Now let's look at some exercises that you can do yourself at home.

Muscular progressive relaxation according to Jacobson

The session is done while sitting. You need to lean your head against the wall, put your hands on the armrests. First, you should cause tension in yourself in all muscles sequentially, while this should occur on inspiration. We give ourselves a feeling of warmth. In this case, relaxation is accompanied by a very fast and rather sharp exhalation. Muscle tension time is about 5 seconds, relaxation time is about 30 seconds. In addition, each exercise must be done 2 times. This method is great for kids too.

1. Muscles of the hands. Stretch your arms forward, spread in different sides fingers. You need to try to reach the wall with your fingers like that.
2. Brushes. Clench your fists as hard as possible. Imagine that you are squeezing water out of a compressible icicle.
3. Shoulders. Try to reach the earlobes with your shoulders.
4. Feet. Reach to the middle of the leg with your toes.
5. Stomach. Make your stomach stone, as if reflecting a blow.
6. Thighs, shins. The toes are fixed, the heels are raised.
7. Middle 1/3 of the face. Wrinkle your nose, squint your eyes.
8. Upper 1/3 of the face. Wrinkle forehead, surprised face.
9. Lower 1/3 of the face. Fold your lips with a "proboscis".
10. Lower 1/3 of the face. Take the corners of the mouth to the ears.

self instructions

We all say something to ourselves. We give ourselves instructions, orders, information for a specific problem solving or instruction. In this case, the person may start with a verbalization that will eventually become part of the entire behavioral repertoire. People are taught such direct instructions. At the same time, in some cases they become "counter-instructions" to aggression, fear, and others. At the same time, self-instructions with approximate formulas are applied according to the steps below.

1. Prepare for the stressor.

• “It's easy to do. Remember humor."
• "I can create a plan to deal with this."

2. Responding to provocations.

• "As long as I remain calm, I am in complete control of the whole situation."
• “In this situation, anxiety will not help me. I'm absolutely sure of myself."

3. Reflection of experience.

• If the conflict is unresolvable: “Forget about the difficulties. To think about them is only to destroy yourself.
• If the conflict is resolved or the situation is handled well: "It wasn't as scary as I expected."

Cognitive Psychotherapy

Cognitive Psychotherapy(English) cognitive therapy) - one of the directions of the modern cognitive-behavioral direction in psychotherapy, developed by A. Beck and based on the position of the defining role cognitive processes(and first of all thinking) in the emergence of various kinds of psychological problems and mental disorders(eg depression).

System Creator

Judith S. Beck. Cognitive therapy: a 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 solving psychological problems lies in the minds of patients.

Aleksandrov 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, in textbooks published in last years in Russian, the question of the existence of differences between the two most influential variants of cognitive therapy - CT by A. Beck and REBT by A. Ellis is not considered. 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 Beck's cognitive therapy, 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 normal development and factors of occurrence of mental pathology.
2. High efficiency, confirmed by numerous studies conducted on different nosological groups (clinical focus): depression, anxiety-phobic disorders, psychosomatic diseases, loneliness, anorexia, bulimia, personality disorders, schizophrenia.
3. Target orientation and manufacturability: for each nosological group exist psychological model describing the specifics of violations; accordingly, the “targets of psychotherapy”, its stages and techniques are highlighted.
4. Short-term and economical approach (unlike, for example, psychoanalysis): from 20-30 sessions.
5. 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 interpretation by the subject 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), in the center of which lies 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 of prolonged stay in a confined space) and biological predisposition (constitutional factor). E. T. Sokolova proposed the concept of differential diagnosis and psychotherapy of two types of depression, based on the integration of CT and the psychoanalytic theory of object relations:
   • 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 a vicious circle of 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
   • positive/negative
   • idiosyncratic/universal. Example: depression - maladaptive, negative, idiosyncratic.
2. automatic thoughts. 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 common to 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 his 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). Psychodynamically, this phenomenon can be classified as defense mechanism splitting, which indicates the "diffusion of self-identity".
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 a high level of claims and a belief in 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 settings:

• 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 relationship

The client and therapist must agree on what problem they are to work on. It is the solution of problems (!), and not the change in the personal characteristics or shortcomings 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 on 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 and count how many people turned to you." Naturally, automatic thought does not coincide with reality! The bottom line: there is a hypothesis, it must be tested empirically.
• 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:

• Detect your negative automatic thoughts
• Find connections between knowledge, affect and behavior
• Find facts for and against these 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 automatic thoughts:

1. empirical verification("experiments"). Ways:
   • Find arguments for and against
   • Designing an Experiment to Test a Judgment
   • 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.
2. Revaluation methodology. Checking the likelihood of alternative causes of an event.
3. 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.
4. 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.
5. 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.
6. Purposeful repetition. Re-enactment of the desired behavior, repeated testing of various positive instructions in practice, which leads to increased self-efficacy.
7. 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: Loud command “stop!” - the negative image of the imagination is destroyed.
   • Repetition technique: repeatedly mentally scroll through the fantasy image - it is enriched with realistic ideas and more probable content.
   • 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.
   • Positive imagination: positive image replaces the negative and has a relaxing effect.
   • Constructive imagination (desensitization): the patient ranks the expected event, which leads to the fact that the forecast loses its globality.

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.

Literature

• Beck A., Judith S. Cognitive Therapy: A Complete Guide = Cognitive Therapy: Basics and Beyond - M .: Williams, 2006. - S. 400. -..
• Alexandrov A. A. Modern psychotherapy. - SPb., 1997. - . (Lectures on Cognitive Therapy Nos. 5, 6 and 13).
• Beck A, Rush A, Sho B, Emery G. Cognitive therapy for depression. - St. Petersburg: Peter, 2003. - .
• Beck A., Freeman A. Cognitive psychotherapy for personality disorders. - St. Petersburg: Peter, 2002.
• McMullin R. Workshop on Cognitive Therapy. - SPb., 2001.
• Vasilyeva O. B. Literature on cognitive-behavioral psychotherapy
• Cognitive-behavioral approach in psychotherapy and counseling: Reader / Comp. T. V. Vlasova. - Vladivostok: GI MGU, 2002. - 110 p.
• Patterson S., Watkins E. Theories of psychotherapy. - 5th ed. - St. Petersburg: Peter, 2003. - Ch. eight.
• Sokolova E. T. Psychotherapy: Theory and practice. - M.: Academy, 2002. - Ch. 3.
• Fedorov A.P. Cognitive-behavioral psychotherapy. - St. Petersburg: Peter, 2002. - .
• S.V. Kharitonov Guide to cognitive-behavioral psychotherapy.-M.: Psychotherapy, 2009.
• A. B. Kholmogorova. Current trends in modern cognitive psychotherapy. (Lecture given on November 18, 2009 at MSUPU).
• Articles by prof. A. B. Kholmogorova on cognitive therapy in email. library MSUPE (available for free download), including: "Garanyan N. G., Kholmogorova A. B., Yudeeva T. Yu. Perfectionism, depression and anxiety // Moscow Journal of Psychotherapy. - 2001. - No. 4 ".
• Kholmogorova A. B., Garanyan N. G. Cognitive-behavioral psychotherapy // The main directions of modern psychotherapy / Ed. ed. A. M. Bokovikova - M .: Kogito-center, 2000. - S. 224-267. - (Modern psychotherapy). - 5000 copies. - .
• Moscow Psychotherapeutic Journal - No. 3/1996; No. 4/2001. (Special Issues on Cognitive Therapy).
• Milton J. Psychoanalysis and cognitive behavioral therapy - competing paradigms or common ground? // Magazine practical psychology and psychoanalysis. - 2005. - No. 4.
• E-books on cognitive-behavioral psychotherapy at

see also

Notes

Internet resources

• Community of Cognitive Behavioral Therapists (cbt.depressii.net)
• Cognitive psychotherapy http://cognitive-therapy.ru
• Beck Institute for Cognitive Therapy and Research