Basic principles of cognitive behavioral therapy

1. The client’s behavior, on the one hand, and his thoughts, feelings, psychological processes and their consequences - on the other hand - have a mutual influence on each other. As Bandura (1978) said, behavior is “bilaterally determined.” CBT theory states that cognition is not the primary source or cause of maladaptive behavior. The client's thoughts influence his feelings to the same extent as feelings influence his thoughts. CBT views thought processes and emotions as two sides of the same coin. Thought processes are only a link, often not even the main one, in the chain of causes. For example, when a therapist is trying to determine the likelihood of relapse for unipolar depression, the therapist can make a more accurate prediction by understanding how critical the client's spouse is rather than relying on cognitive measures (Hooley et al., 1986).

2. Cognitive can be considered as a set of cognitive events, cognitive processes and cognitive structures. The term "cognitive events" refers to automatic thoughts, internal dialogue and imagery. I would like to note that this does not mean that a person is constantly talking to himself. Rather, we can say that human behavior in most cases is thoughtless and automatic. Abelson (1976), Langer (1978) and Thorngate (1976) say it is "on script". But there are cases in which automatism is interrupted, when a person needs to make a decision under conditions of uncertainty, and in these cases inner speech “turns on.” In cognitive behavioral theory, it is believed that its content can influence a person’s feelings and behavior. But, as already mentioned, the way a person feels, behaves and interacts with others can also significantly influence his thoughts. According to CBT theory, cognitive causes (so-called "irrational" beliefs, cognitive errors, or special thoughts) do not cause emotional disorders or maladaptive behavior. This view is rather considered a simplification that does not correspond to scientific data. Cognitive is only part of a complex system of interacting processes. Cognitive events represent only one side of the cognitive totality. There are also cognitive processes. Social, cognitive, and developmental psychology have done much to describe cognitive processes, particularly confirmation bias, heuristic thinking, and metacognition. (A more complete description of these cognitive processes can be found in the following references: Meichenbaum & Gilmore, 1984; Hollon & Kriss, 1984; Taylor & Crocker, 1981)). In short, confirmation bias occurs when a person strictly holds certain views about himself and the world around him, rarely paying attention to facts that refute the correctness of these views. Heuristic thinking is the use of “habitual thinking” when decisions need to be made under conditions of uncertainty (e.g., availability and representativeness heuristics described by Tversky & Kahneman, 1977). Moreover, emotional state a person (for example, depression, anxiety, etc.) can influence specific heuristic examples from the past and color them in their own way. A person does not just react to events, he relies on various ready-made examples from the past, depending on his mood at the moment. Thus, the client’s emotions influence what information he will choose as a guide to action, what conclusions he will draw, and what explanations he will offer for his behavior. Metacognition is the processes of self-regulation and reflection on them. The therapist helps the client develop the ability to “notice,” “grasp,” “interrupt,” and “monitor” their thoughts, feelings, and behaviors. In addition, the psychotherapist must make sure that with positive changes in his behavior, the client is aware that he himself has made them. Finally, CBT emphasizes the central role of cognitive structures or schemas. Initially, greater importance was attributed to cognitive events, but gradually the emphasis shifted to schemas, the concept of which, as Bartlett (1932) noted, was borrowed from information processing theory. Schemas are a cognitive representation of past experience that influences the perception of present experience and helps to systematize new information(Goldfried, 1988; Neimeyer & Feixas, 1990). Safran & Segal (1990) say that schemas are more like unspoken rules that organize and guide information about a person's personality. Schemas influence event appraisal processes and coping processes (Meichenbaum, 1977).

3. Because schemas are so important, the primary task of the cognitive behavioral therapist is to help clients understand how they construct and interpret reality. In this regard, CBT works in a constructivist manner. The therapist also helps clients see how they unintentionally select from the information flow only what confirms their existing ideas about themselves and about the world around them. Cognitive-behavioral theory supports an interactive view of behavior (Coyne & Gotlib, 1983; Kiesler, 1982; Wachtel, 1982). For example, people with chronic depression often behave in such a way that others turn away from them, and this once again confirms the conviction that they have formed in their rejection and shows that their fear of loneliness is justified. Therefore, when a depressed patient claims that “nobody loves” him, it is more likely exact description than cognitive distortion. However, he does not understand that he himself unwittingly caused such an attitude towards himself. The task of the psychotherapist in this case is to help the client break the vicious circle. Because CBT is constructivist, it does not believe that there is “one reality” or that the therapist’s job is to educate the client or correct misconceptions (such as thinking errors or irrational thoughts). Rather, CBT recognizes the existence of “multiple realities,” as in Kurosawa's film Rashomon. The common task of client and therapist is to understand how the client creates these realities and at what cost he pays for it. Moreover, it is necessary to answer the question: does he want to pay with his emotions and relationships with other people? What does he lose by continuing to adhere to his views on himself and the world? These questions are answered not in the abstract, but by experimenting with emotions during psychotherapeutic sessions, creating what Alexander and French called “corrective emotional experiences” (Alexander & French, 1946). Together with the client, the possibilities of changing personal constructs and behavior are considered. In addition, during the sessions, great attention is paid to considering obstacles that may stand in the way of change.

4. The current version of CBT has disagreements with psychotherapeutic approaches that take the positions of rationalism and objectivism. As Neimeyer (1985) and Mahoney (1988) noted, the rationalist approach requires the client to monitor and correct “incorrect” or “irrational” beliefs. The therapist helps the client develop a more accurate and objective view of reality through logical challenge, instruction, and the collection of empirical evidence that subjects the client's incorrect beliefs to the test of reality. In contrast, CBT, as a phenomenologically oriented branch of psychotherapy, seeks to explore the client's worldview through non-directive, reflective methods. The therapist tries to see the world through the client's eyes, rather than challenging or interpreting his thoughts. The main way to achieve this goal is this: the psychotherapist “selects” key words and phrases from the client’s speech and repeats them with interrogative intonations, but without distorting the meaning. The therapist can also use information about the client's past and behavior during therapy sessions to help the client understand their feelings.

5. CBT imparts great value processes of collaboration and discovery. An indicator of the good work of a psychotherapist is the situation when the client manages to offer an answer to a question before him. The therapist helps the client gather information (for example, how the problem changes depending on the situation) and then asks what could have been done differently. If the client says: “I don’t know,” the psychotherapist echoes him: “I don’t know either. Let’s think about how we can find out.” By saying “we”, involving the client in cooperation, the psychotherapist, as it were, invites the client to share responsibility, giving him the strength to work on his problem himself. The goal of CBT is to help the client become their own therapist. To achieve this goal, the therapist must not be didactic. With this position of the psychotherapist, the client begins to experiment with his beliefs, opinions and assumptions, checking their correctness, gradually moving on to experiments with new types of behavior. Some patients require extensive behavioral training (eg, modeling, rehearsal, role-playing) before they can proceed to such experiments.
6. Relapse prevention is extremely important to CBT. Its importance was originally emphasized by Marlatt and Gordon (1985) when working with alcoholics and drug addicts, but relapse prevention is given greater importance

In CBT in general. Psychotherapists, together with clients, consider high-risk situations in which a relapse may occur, and also analyze the client’s thoughts and feelings that could lead to a relapse. They are also worked with during psychotherapeutic sessions (for example, see: Meichenbaum, 1985). Cognitive behavioral therapists believe that clients, like scientists, learn from mistakes and failures. Without failures there would be no forward movement. In short, therapists help clients view failures and disappointments as lessons and challenges rather than disasters. The cognitive-behavioral psychotherapist serves as a channel of hope by combating the dejection and hopelessness, helplessness, and vulnerability with which clients come to him (Frank, 1974). He may even tell the client that the symptoms are a good sign that the client's feelings are okay: “Considering everything you've been through, I'm not surprised you're depressed (anxious, angry). I'm worried.” if it weren't so." In other words, what is essential to the process of behavior change is not that the client is depressed, anxious, or angry (all of which are normal reactions to the vicissitudes of life), but rather how he feels about these emotional reactions. Cognitive behavioral therapy uses the entire range of cognitive restructuring techniques: social comparison, paradoxical techniques, reframing, etc.

7. All of these techniques are only effective in the context of a collaborative relationship. The relationship between client and therapist is extremely important for achieving positive results. Safran & Segal (1990) recently reviewed the literature examining the various variables that influence the outcome of psychotherapy and showed convincing evidence that the relationship in psychotherapy has a much greater influence on the outcome than specific technical factors (ratio 45% to 15%). Cognitive-behavioral psychotherapists place great emphasis on establishing and maintaining a collaborative relationship with the client. It is very important for them that during the sessions there is an atmosphere of warmth, empathy, emotional “consonance,” acceptance and trust. Psychotherapeutic relationships are ideally a model for building relationships outside the psychotherapist's office. The relationship with the therapist gives the client the courage to change. Moreover, as Meichenbaum and Turk (1987) note, such a relationship becomes an important factor in helping to overcome client resistance. This is extremely important because it has been reported that 70% of patients drop out of psychotherapy after the 4th session (Phillips, 1986). As Safran & Segal (1990, p. 35) noted, CBT recognizes “the inextricable connection between psychotherapeutic techniques, the personal qualities of the therapist and his relationship with the client. Very often psychotherapy becomes too didactic, more reminiscent of elementary logic. With this approach the client does not have the opportunity to understand his own view of things and experiment with a new attitude towards them, try to create a different idea of ​​reality and think about it possible consequences. Collaboration in the process of psychotherapy gives clients the courage to undertake such personal and behavioral experiments. Often a change in attitude towards oneself becomes the result of behavioral changes and their consequences.

8. All this is associated with great emotional stress. Emotions play a very important role in CBT. According to Greenberg and Safran (1986), emotions are often given too little attention in psychotherapy. CBT believes that emotions are extremely important for understanding clients' cognitive structures and schemas. Just as Freud considered emotions to be the “royal road to the unconscious,” we consider emotions to be the “royal road” to personality patterns. There are many ways to “reach” the client’s emotions; Here we will only touch on the use of transfer. When communicating with a psychotherapist, clients often use emotional patterns formed in communication with significant people in the past. The psychotherapist, as a participant-observer of these relationships, discusses them with the client. Here the unit of analysis is not automatic thoughts or ways of thinking, but the manner in which the patient interacts with the therapist. The psychotherapist, together with the client, explores both the emotions that arise during psychotherapy and the various factors that led to today's emotional problems. In a nutshell. CBT helps the client make sense of their behavior. As a result, the client begins to understand that he is not crazy and that his beliefs are not pathological, as some theorists say (Weiss & Sampson, 1986). We try to bring the client to the realization that he has certain beliefs that are understandable because of what he has experienced, but that at the moment these beliefs, having been transferred to new life circumstances, have become an obstacle to achieving his goals. As systems-oriented psychotherapists say, the solutions to problems found by the client are often themselves part of the problems. CBT believes that the client's understanding of what is happening should be assessed not in terms of its correctness, but in terms of its suitability given the circumstances. Neimeyer and Feixas (1990) noted that in a constructivist approach, the therapist is more interested in the suitability of a meaning system for adaptation than in its correctness. Taylor and Brown (1988) found that motivated thinking (adherence to illusions, denial of the existence of a problem, positive views of oneself and the environment) is often adaptive. This also seems to be true of illusory beliefs that do not translate into meaningful action. Where inaction does not cause harm, motivated thinking can be adaptive (Kunda, 1990). In cognitive behavioral therapy, it is not common practice to attack the client's beliefs head-on, as this can lead to them becoming “stuck” (Kmglansky, 1990). A psychotherapist who wants to help a client change beliefs must take "detours." There are different ways to make emotionally charged beliefs open to change: you can make the client your ally, reduce it defensive reactions, or you can show him his beliefs in an exaggerated form to get his reaction. The change process is typically saturated with “hot” cognitions (Zajonc & Markus, 1984). Cold cognitions—providing information, challenging, logical—rarely help change the client's persistently held beliefs and accompanying behaviors (Meichenbaum & Turk, 1987).

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

Founders of the system

In the middle of the 20th century, the works of the pioneers of cognitive behavioral therapy (hereinafter CT) A. Beck and A. Ellis became very famous and widespread. Aaron Beck originally received psychoanalytic training, but, disillusioned with psychoanalysis, created his own model of depression and new method treatment affective disorders which is 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. - P. 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 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, cognition. New approach - cognitive therapy- believes that emotional disorders can be approached in a completely different way: the key to understanding and solution psychological problems is in the minds of patients.

Alexandrov A. A. Modern psychotherapy. - St. Petersburg: Academic Project, 1997. - P. 82.

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

To achieve these goals, a cognitive psychotherapist helps the client solve the following tasks: 1) understand the influence of thoughts on emotions and behavior; 2) learn to identify and observe negative automatic thoughts; 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 fertile ground for the occurrence 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 most popular of which are described below.

Methodology and features of cognitive psychotherapy

Today, CT is at the intersection of cognitivism, behaviorism and psychoanalysis. As a rule, in textbooks, published in recent years in Russian, do not address 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. An exception is the monograph by G. Kassinov and R. Tafrate with a foreword by Albert Ellis.

As the founder of rational emotive behavior therapy (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 techniques, and Chapter 14 introduces some basic REBT techniques. … Both chapters are excellently written and reveal both many similarities and the main differences between these approaches. … But I would also like to point out that the REBT approach certainly emphasizes emotional-memory-(evocative-)experiential modes more than cognitive therapy.

Preface / A. Ellis // Kassinov G., Tafreyt R. Ch. Psychotherapy of anger. - M.: AST; St. Petersburg: Sova, 2006. - P. 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 are not discussed or questioned. ... The psychotherapist does not discuss reliability, 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: Sova, 2006. - P. 328.

Features of CT:

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

Basic theoretical principles

1. The way an individual structures situations determines his behavior and feelings. Thus, 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. Affective pathology is a strong exaggeration of normal emotion, resulting from incorrect interpretation under the influence of many factors (see point No. 3). The central factor is “private possessions (personal space)” ( personal domain), at the center of which lies the Ego: emotional disturbances depend on whether a person perceives events as enriching, depleting, threatening, or encroaching on his domain. Examples:
   • Sadness arises from the loss of something valuable, that is, the deprivation of private possession.
   • Euphoria is the feeling or expectation of acquisition.
   • Anxiety is a threat to physiological or psychological well-being.
   • Anger results from the feeling of being directly attacked (either intentionally or unintentionally) or of a violation of the individual's laws, morals, or standards.
3. Individual differences. They depend on past traumatic experiences (for example, a situation of prolonged stay in a confined space) and biological predisposition (constitutional factor). E. T. Sokolova proposed the concept differential diagnosis and psychotherapy for two types of depression, based on the integration of CT and psychoanalytic object relations theory:
   • Perfectionistic melancholy(occurs in the so-called “autonomous personality”, according to Beck). It is provoked by frustration of the need for self-affirmation, achievement, and autonomy. Consequence: development of the compensatory structure of the “Grandiose Self”. Thus, here we're talking about about the narcissistic personality organization. Strategy of psychotherapeutic work: “containment” (careful attitude towards heightened pride, wounded pride and feelings 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 clinging to the Other. Strategy of psychotherapeutic work: “holding” (emotional “pre-feeding”).
4. The normal functioning of the cognitive organization is inhibited under the influence of stress. Extremist judgments, problematic thinking arise, concentration is impaired, etc.
5. Psychopathological syndromes (depression, anxiety disorders, etc.) consist of hyperactive patterns with unique content that characterize a particular syndrome. Examples: depression - loss, anxiety disorder - threat or danger, etc.
6. Intense interactions with other people create a vicious circle of maladaptive cognitions. A wife suffering from depression, misinterpreting her husband’s frustration (“I don’t care, I don’t need her...” instead of the real “I can’t help her”), attributes a negative meaning to it, continues to think negatively about herself and her relationship with her husband, withdraws, and, as a consequence, her maladaptive cognitions are further strengthened.

Key Concepts

1. Schemes. These are cognitive formations that organize experience and behavior, this is a system of beliefs, deep ideological attitudes of a person in relation to himself and the world around him, influencing current perception and categorization. Schemes can be:
   • adaptive/non-adaptive. An example of a maladaptive schema: “all men are bastards” or “all women are bitches.” Of course, such schemes do not correspond to reality and are an excessive generalization, 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 inclined in advance, and the interlocutor may understand this and be offended.
   • positive/negative
   • idiosyncratic/universal. Example: depression - maladaptive, negative, idiosyncratic.
2. Automatic thoughts. These are thoughts that the brain records in the “fast” area of ​​​​memory (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 repeatedly slowly thinking about this thought, 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 and return them from the area quick memory again into the area of ​​slow rethinking in order to remove incorrect judgments from the subconscious and rewrite them with correct counterarguments. Main characteristics of automatic thoughts:
   • Reflexivity
   • Collapse and compression
   • Not subject to conscious control
   • Transience
   • Perseveration and stereotyping. Automatic thoughts are not the result of thinking or reasoning; they are subjectively perceived as reasonable, even if they seem absurd to others or contradict obvious facts. Example: “If I get a “good” grade on 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 divorce,” “Everything I I do it, I do it poorly.”
3. Cognitive errors. These are supervalent and affectively charged schemas that directly cause cognitive distortions. They are common to everyone psychopathological syndromes. Types:
   • Arbitrary conclusions- 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, followed by their generalization.
   • Selective abstraction- focusing the individual’s attention on any details of the situation while ignoring all its other features.
   • Exaggeration and understatement- opposite assessments of oneself, situations and events. The subject exaggerates the complexity of the situation while simultaneously downplaying his ability to cope with it.
   • Personalization- an individual’s attitude towards external events as having something to do with him, when in reality this is not the case.
   • Dichotomous Thinking(“black and white” thinking or maximalism) - assigning oneself or any event to one of two poles, positive or negative (in absolute terms). In a psychodynamic sense, this phenomenon can be qualified as a protective mechanism of splitting, which indicates the “diffusion of self-identity.”
   • Ought- excessive focus on “I should” act or feel in a certain way, without assessing the real consequences of such behavior or alternative options. Often arises from previously imposed standards of behavior and thought patterns.
   • Prediction- an 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 and 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 one or another type of psychopathology (see below).

Theory of psychopathology

Depression

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

• Negative self-image: “I’m inferior, I’m a failure, at the very least!”
• Negative assessment of the surrounding world and external events: “The world is merciless to me! Why is all this falling on me?”
• Negative assessment of the future. “What can I say? I simply have no future!”

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

• Fixation on a 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 the Ought

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 loss of control (for example, over your body, as in the case of fear of getting sick). Claustrophobia - fear of enclosed spaces; mechanism (and in agoraphobia): fear that in case of danger help may not arrive in time. Topics:

• Anticipation of negative events in the future, so-called. “anticipation of all kinds of misfortunes.” With agoraphobia: fear of dying or going crazy.
• The discrepancy between the level of aspirations 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.
• Persistent perception of inevitable failure in trying to establish interpersonal relationships, to be humiliated, ridiculed or rejected.

Perfectionism

Phenomenology of perfectionism. Main parameters:

• High standards
• All or nothing thinking (either complete success or complete failure)
• Focusing on failures

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

Psychotherapeutic relationship

The client and therapist must agree on what problem they want to work on. It is problem solving (!), and not changing the patient’s personal characteristics or shortcomings. The therapist must be very empathic, natural, congruent (principles taken from humanistic psychotherapy); there should be no directiveness. 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 look at me,” therapist: “Try to walk normally down the street and count how many people turn to look at you.” Usually this 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, do have a real factual basis - it’s all about how the mentally ill person 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 from one point, does not look around at all, or looks around with fear at those around him, then such a person will certainly attract attention to himself. They will actually turn around, look at him and discuss him - simply because passers-by are interested in why he behaves this way. In this situation, a psychologist can help the client understand that the interest of others is caused by his 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 goals:
  1. Clarify or identify problems
  2. Help in identifying thoughts, images, sensations
  3. Explore the meaning of events for the patient
  4. Assess the consequences of maintaining maladaptive thoughts and behaviors.
• Guided Cognition: The therapist-guide encourages patients to address facts, evaluate probabilities, gather information, and put it all to the test.

Techniques and methods of cognitive psychotherapy

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

• Identify your negative automatic thoughts.
• Find connections between knowledge, affect and behavior.
• Find facts for and against automatic thoughts.
• Look for more realistic interpretations for them.
• Learn to identify and change disorganizing beliefs that lead to distortion of skills and experience.

Specific methods for identifying and correcting automatic thoughts:

1. Writing down thoughts. The psychologist can ask the client to write down on paper what thoughts arise in his head when he tries to do required action(or not do an unnecessary action). It is advisable to write down the thoughts that come to mind at the moment 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 therapists encourage their clients to jot down their thoughts in a diary over the course of several days to understand what the person thinks about most often, how much time they spend on it, and how strong emotions experiences from his thoughts. For example, American psychologist Matthew McKay recommended that his clients divide a diary page into three columns, where they briefly indicate the thought itself, the hours of time spent on it, and an assessment of their emotions on a 100-point scale ranging from: “very pleasant/interesting” - “ indifferent" - "very unpleasant/depressing." The value of such a diary is also that sometimes even the client himself cannot always accurately indicate the reason for his experiences, then the diary helps both himself and his psychologist find out what thoughts affect his well-being during the day.
3. Distance. 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 involves 3 components:
   • awareness of the automaticity of a “bad” thought, its spontaneity, the understanding that this pattern arose earlier under different circumstances or was imposed by other people from the outside;
   • awareness that a “bad” thought is maladaptive, that is, it causes suffering, fear or disappointment;
   • the emergence of doubt 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 at the university).
4. Empirical verification(“experiments”). Methods:
   • Find arguments for and against automatic thoughts. It is also advisable to write down these arguments on paper so that the patient can re-read it whenever these thoughts come to his mind 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. Here it is also necessary to take into account the long-term perspective, and not just the short-term benefit (for example, in the long run, the problems from drugs will be many times greater than the temporary pleasure).
   • Constructing an experiment to test a judgment.
   • Conversation with witnesses of past events. This is especially true when mental disorders ah, where memory is sometimes distorted and replaced by fantasy (for example, in schizophrenia) or, if the delusion is caused by an incorrect interpretation of the motives of another person.
   • The therapist turns to his experience, fiction and academic literature, statistics.
   • The therapist incriminates: points out logical errors and contradictions in the patient’s judgments.
5. Revaluation technique. Checking the probability of alternative causes of an event.
6. Decentration. With social phobia, patients feel like the center of everyone's attention and suffer from it. Empirical testing of these automatic thoughts is also needed here.
7. Self-expression. Depressed, anxious, etc. patients often think that their illness is under control higher levels consciousness, constantly observing themselves, they understand that symptoms do not depend on anything, and attacks have a beginning and an end. Conscious self-observation.
8. Decatastrophizing. At anxiety disorders Oh. Therapist: “Let's see what would happen if...”, “How long will you experience such negative feelings?”, “What will happen then? Will you 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. Playing out the desired behavior, repeatedly trying out various positive instructions in practice, which leads to increased self-efficacy. Sometimes the patient completely agrees with the correct arguments during psychotherapy, but quickly forgets them after the session and again returns to the previous “wrong” arguments, since 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 re-read them regularly.
10. Using the Imagination. In anxious patients, it is not so much “automatic thoughts” that predominate as “obsessive images”, that is, it is not thinking that maladapts, but imagination (fantasy). Types:
    • Stopping technique: loud command to yourself “stop!” - the negative way of thinking or imagining stops. It can also be effective in stopping obsessive thoughts in some mental illnesses.
    • Repetition technique: repeat the correct way of thinking several times to destroy the formed stereotype.
    • Metaphors, parables, poems: the psychologist uses such examples to make the explanation more understandable.
    • 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 severe failure, 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. Reassessment of values. Often the cause of depression is unfulfilled desires or excessively high demands. In this case, a 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 abandon achieving this goal altogether, discard an unfulfillable desire, reduce requests, set more realistic goals for oneself, for starters, try to get more comfortable with what you have or find something substitute. This is true in cases where the cost of refusing to solve a problem is lower than suffering from the problem itself. However, in other cases, it may be better to tense up and solve the problem, especially if delaying the solution only makes the situation worse and causes more suffering for the person.
12. Replacing emotions. Sometimes the client needs to come to terms with his past negative experiences and change his emotions to more adequate ones. For example, sometimes it will be better for a victim of a crime not to replay the details of what happened in his memory, but to say to himself: “It’s very unfortunate that this happened to me, but I won’t let my offenders ruin the rest of my life, 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, which will allow you to build your future life more comfortably.
13. Role reversal. Ask the client to imagine that he is trying to console a friend who is in trouble. similar situation. What could you say to him? What do you recommend? What advice could your loved one give you in this situation?
14. Action plan for the future. The client and therapist jointly develop a realistic “action plan” for the client for the future, with specific conditions, actions and deadlines, and write this plan down on paper. For example, if a catastrophic event occurs, the client will perform a certain sequence of actions at the designated time, and before this event occurs, the client will not torment himself needlessly with worries.
15. Identifying alternative causes of behavior. If all the “correct” arguments have been presented, and the client agrees with them, but continues to think or act in a clearly illogical way, then you should look alternative reasons such behavior that the client himself is not aware of or prefers to remain silent about. For example, with obsessive thoughts, the very process of thinking often brings a person great satisfaction and relief, since it allows him to at least mentally imagine himself as a “hero” or “savior,” solve all problems in fantasies, punish enemies in dreams, correct his mistakes in an imaginary world, etc. .d. Therefore, a person scrolls through such thoughts again and again, no longer for the sake of a real solution, but for the sake of the very process of thinking and satisfaction; gradually this process draws the person deeper and deeper like a kind of drug, although the person understands the unreality and illogicality of such thinking. In particularly severe cases, irrational and illogical behavior may even be a sign of a serious mental illness(eg, obsessive-compulsive disorder or schizophrenia), then psychotherapy alone may not be enough, and the client also needs the help of medication to control thinking (i.e., requires intervention from a psychiatrist).

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

• With schizophrenia, patients sometimes begin to conduct mental dialogues with imaginary images of people or otherworldly beings (so-called “voices”). The psychologist, in this case, can try to explain to the schizophrenic that he is not talking with real people or creatures, but with those created by him artistic images these creatures, thinking alternately for themselves and then for this character. Gradually, the brain “automates” this process and begins to produce phrases that are suitable for the invented character in a given situation automatically, even without a conscious request. You can try to explain to the client that normal people also sometimes have conversations with imaginary characters, 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, thinking in turn for several characters at once. However, a normal person understands well that this image is fictitious, so he is not afraid of it and does not treat it as a real being. Brain healthy people does not attach interest or importance to such characters, and 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 photograph in the table and forget about it, because it doesn’t matter, and if it were a living person, they wouldn’t do that to him. When a schizophrenic realizes that his character is just a figment of his imagination, he, too, will begin to handle him much more easily and will stop pulling this image out of his memory when it is not necessary.

• Also, with schizophrenia, the patient sometimes begins to mentally replay a fantasy image or plot many times, gradually such fantasies are deeply recorded in memory, enriched with realistic details and become very believable. However, this is the danger that a 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 with the help of external reliable sources: documents, people whom the patient trusts, scientific literature, conversation with witnesses, photographs, video recordings, constructing an experiment to test judgment, etc.

• In obsessive-compulsive disorder, when an obsessive thought occurs, it may be helpful for the patient to repeat counter-arguments several times about how they are being harmed intrusive thoughts how he uselessly wastes his precious time on them, that he has more important matters 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, at work, etc. As mentioned above, it is better to write down such useful counterarguments on paper, to re-read them regularly and try to remember them by heart.

The effectiveness of cognitive psychotherapy

Factors of 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, once a good therapist feels the dullness and impersonality of therapy (“solving problems according to formal logic”), he is not afraid of self-disclosure, is not afraid of using imagination, parables, metaphors, etc. p.
2. The right psychotherapeutic relationship. Taking into account the patient’s automatic thoughts about the psychotherapist and the proposed tasks. Example: Automatic thought of the patient: “I will write 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 truly live.” Therapist: “The diary is just a separate help, there will be no immediate effects; your journal entries are mini-experiments that give you new information about yourself and your problems.”
3. High-quality application of techniques, an informal approach to the CT process. Techniques must be applied according to specific situation, a formal approach dramatically reduces the effectiveness of CT and can often generate new automatic thoughts or frustrate the patient. Systematicity. Accounting for feedback.
4. Real problems - real effects. Effectiveness decreases if the therapist and client do whatever they want, ignoring the real problems.

This method of psychotherapy addresses the conscious mind and helps to free ourselves from stereotypes and preconceived ideas that deprive us of freedom of choice and push us to act according to a pattern. The method allows, if necessary, to correct the patient’s unconscious, “automatic” conclusions. He perceives them as truth, but in reality they can greatly distort real events. These thoughts often become the source of painful emotions, inappropriate behavior, depression, anxiety disorders and other diseases.

Operating principle

Therapy is based on working together therapist and patient. The therapist does not teach the patient how to think correctly, but together with him he understands whether the habitual type of thinking helps him or hinders him. The key to success is the active participation of the patient, who will not only have to work during the sessions, but also do homework.

If at the beginning therapy focuses only on the patient’s symptoms and complaints, then gradually it begins to affect unconscious areas of thinking - deep-seated beliefs, as well as childhood events that influenced their formation. The principle of feedback is important - the therapist constantly checks how the patient understands what is happening in therapy and discusses possible errors with him.

Work progress

The patient, together with the psychotherapist, finds out under what circumstances the problem manifests itself: how “automatic thoughts” arise and how they affect his ideas, experiences and behavior. In the first session, the therapist only listens carefully to the patient, and in the next they discuss in detail the patient’s thoughts and behavior in numerous everyday situations: what does he think about when he wakes up? And at breakfast? The goal is to make a list of moments and situations alarming.

The therapist and patient then outline a program of work. It includes tasks that must be completed in places or circumstances that cause anxiety - riding an elevator, having dinner at public place… These exercises allow you to reinforce new skills and gradually change behavior. A person learns to be less rigid and categorical, to see different facets of a problem situation.

The therapist constantly asks questions and explains points that will help the patient understand the problem. Each session is different from the previous one, because each time the patient moves forward a little and gets used to living in accordance with new, more flexible views without the support of a therapist.

Instead of “reading” other people’s thoughts, a person learns to distinguish between his own, begins to behave differently, and as a result, his emotional state changes. He calms down, feels more alive and free. He begins to be friends with himself and stops judging himself and other people.

In what cases is this necessary?

Cognitive therapy is effective in treating depression, panic attacks, social anxiety, obsessive-compulsive disorder and disorders eating behavior. This method is also used to treat alcoholism, drug addiction and even schizophrenia (as a supportive method). At the same time, cognitive therapy is also suitable for working with low self-esteem, relationship difficulties, perfectionism and procrastination.

It can be used both in individual work and in working with families. But it is not suitable for those patients who are not ready to take an active part in the work and expect the therapist to give advice or simply interpret what is happening.

How long should therapy last? How much does it cost?

The number of meetings depends on the client’s willingness to work, the complexity of the problem and his living conditions. Each session lasts 50 minutes. The course of therapy ranges from 5–10 sessions 1–2 times a week. In some cases, therapy may last longer than six months. A consultation with a cognitive psychologist costs from 2,000 to 4,000 rubles.

History of the method

1913. American psychologist John Watson publishes his first articles on behaviorism. He encourages his colleagues to focus exclusively on studying human behavior, on studying the connection between “external stimulus and external reaction (behavior).”

1960s The founder of rational-emotive psychotherapy, American psychologist Albert Ellis, states the importance of the intermediate link in this chain - our thoughts and ideas (cognitions). His colleague Aaron Beck begins to study the field of cognition. Having assessed the results various methods therapy, he came to the conclusion that our emotions and our behavior depend on the style of our thinking. Aaron Beck became the founder of cognitive behavioral (or simply cognitive) psychotherapy.

Last update: 07/17/2014

Cognitive behavioral therapy (CBT) is a type of treatment that helps patients understand the thoughts and feelings that influence behavior. It is commonly used to treat wide range diseases, including phobias, addictions, depression and anxiety. Cognitive behavioral therapy usually lasts a short time and focuses on helping clients with a specific problem. During treatment, people learn to identify and change destructive or anxious thinking patterns that are causing negative impact on behavior.

Basics of Cognitive Behavioral Therapy

The basic concept implies that our thoughts and feelings play a fundamental role in shaping our behavior. For example, a person who thinks too much about plane crashes, runway accidents, and other air disasters may begin to avoid air travel. The goal of cognitive behavioral therapy is to teach patients that they cannot control every aspect of the world around them, but they can take control of how they interpret and interact with the world.
In recent years, cognitive behavioral therapy has become increasingly popular both among clients and therapists themselves. Because this type of treatment, as a rule, 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 helps patients overcome inappropriate behavior in its most varied manifestations.

Types of Cognitive Behavioral Therapy

As the British Association of Behavioral and Cognitive Therapists note, “Cognitive behavioral psychotherapy is a range of treatments based on concepts and principles derived from psychological models of human emotion and behavior. They include both a wide range of approaches to treating emotional disorders and self-help options.”
The following are regularly used by professionals:

• Rational Emotive Behavioral Therapy;
• cognitive therapy;
• multimodal therapy.

Components of Cognitive Behavioral Therapy

People often experience thoughts or feelings that only reinforce their wrong opinion. These opinions and beliefs can lead to problematic behavior that can impact multiple areas of life, including family, romantic relationships, work and school. For example, a person suffering from low self-esteem may have negative thoughts about himself or his own abilities or appearance. As a result, the person may begin to avoid situations of social interaction or refuse, for example, opportunities for advancement at work.
To combat these destructive thoughts and behaviors, the therapist begins by helping the client identify the problematic beliefs. This stage, also known as functional analysis, has important to understand how thoughts, feelings and situations can contribute to inappropriate behavior. This process can be challenging, especially for patients who struggle with over-introspective tendencies, but it can ultimately lead to self-knowledge and insights that are an integral part of the healing process.
The second part of cognitive behavioral therapy focuses on the actual behavior that is contributing to the problem. The client begins to learn and practice new skills that can then be used in real situations. For example, a person suffering from drug addiction can learn coping skills and ways to avoid or cope with social situations that could potentially trigger relapse.
In most cases, CBT is a gradual process that helps a person take additional steps toward behavior change. A person with social anxiety may start by simply imagining themselves in a social situation that causes anxiety. He can then try talking to friends, family members and acquaintances. With constant movement towards the goal, the process seems less complicated, and the goals themselves seem quite achievable.

Application of CBT

I use cognitive behavioral therapy to treat people suffering from a wide range of illnesses - anxiety, phobias, depression and addiction. CBT is one of the most studied types of therapy - in part because the treatment focuses on specific problems and its results are relatively easy to measure.
Cognitive behavioral therapy is often best suited for clients who tend to be self-reflective. For CBT to be effective, a person must be ready for it and must be willing to put in the time and effort to analyze their thoughts and feelings. This kind of self-reflection can be difficult, but it is a great way to learn more about how internal state influences behavior.
Cognitive behavioral therapy is also good for those who need short-term treatment that does not involve the use of medication. One of the benefits of cognitive behavioral therapy is that it helps clients develop skills that can be useful now and in the future.