Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy that emphasizes the importance of how our thoughts and emotions influence our behavior. During cognitive behavioral therapy, patients are asked to focus on their thoughts, beliefs, and attitudes and understand how they relate to problem behavior. By working through this process, a person can learn healthy ways to cope with difficult emotions and challenging life situations. Cognitive behavioral therapy can help a person lead a happy, fulfilling life by changing the way they think and behave.

What is Cognitive Behavioral Therapy?

Unlike other therapeutic strategies, cognitive behavioral therapy focuses on a person's current, rather than past, life situation. Cognitive behavioral therapy emphasizes that people can learn to be their own therapists by developing coping skills when dealing with difficult thoughts and emotions.

Cognitive behavioral therapy is useful for a number of mental health conditions and substance use disorders, including (but not limited to):

Depression
Anxiety disorders
Alcohol use disorder
Methamphetamine addiction
Eating disorders

Since the 1960s, cognitive behavioral therapy has become one of the most common and useful therapeutic models for treating mental health conditions and substance use disorders. Research shows that cognitive behavioral therapy leads to significant improvements in behavior and quality of life.

Basics of CBT

As its name suggests, cognitive behavioral therapy is built around two things: how the client thinks and how he behaves.

CBT is based on the assumption that what happens to a person depends largely on how he structures the world. And this is determined by the way he thinks. CBT, unlike many other psychotherapeutic approaches, postulates that a person's thoughts cause emotions

, and not vice versa.

The most important role here is played by the so-called. automatic thoughts

- these are, oddly enough, thoughts that appear automatically.
Let us explain with an example: while writing this article, the author had to take a few days off to solve some everyday problems. When he learned about this, a whole series of involuntary and, as further analysis showed, destructive thoughts arose in his brain, such as “ I’m a loser
,” “
I won’t succeed
,” “
I’ll be kicked out of GeekTimes
,” and the like.

Automatic thoughts are not always destructive, and moreover, they are not always wrong. But you should treat them with suspicion - as a rule, they are products of the principle of saving resources: the brain is “lazy” to fully calculate the situation and produces the first solution/judgment that comes across. And it often happens that the same brain, if forced to think carefully, will give a completely different assessment or make a completely different decision.

For example, a person who has accumulated minuses in his karma may automatically consider himself defective, but, after thinking carefully, he will understand that he simply made a too harsh and erroneous statement (a one-time mistake does not prove the inferiority of the one who made it).

A synonym for the term “automatic thought” is the word “ cognition

”, which Beck defined as follows: “Cognition is a thought or image that may go unnoticed by you unless you concentrate on it.”[9].

Actually, that part of CBT that is cognitive is about teaching the client to catch his cognitions, become aware of them, check for adequacy and (if necessary) replace them with more adequate thoughts. Those. argue with yourself. And no, this is in no way schizophrenia, this is part of the therapeutic process in CBT called disputation.

Some of the cognitions are disputed by the therapist, some (it must be said - b o

most of it) the client himself.

But in CBT there is also a second part - behavioral. A directive approach works here, where the therapist forces the client to behave in a healthy way, for example, a depressed client who lies in bed most of the day will be tasked with creating (and then implementing) a certain daily routine, including a certain level of activity, and the client with agoraphobia (after appropriate training, of course) will be forced to visit crowded places.

Speaking of “appropriate preparation”. Within the framework of behaviorism (on which the behavioral part of CBT is based), various techniques are possible, but two of them deserve special attention and inclusion in this article.

The first is systematic desensitization

. It is especially good for various kinds of phobias. At the first stage, the client is taught some kind of relaxation technique (muscle relaxation, breathing exercises, etc.), after which he is presented with a stimulus that causes fear.

If we imagine that our hypothetical client is afraid of spiders, then he will be shown a photo of a spider and asked to use a previously learned technique to relax. When the photograph ceases to make an impression, he will be presented with a spider in a jar at a considerable distance and asked to relax. As therapy progresses, the stimulus will increase in intensity until the client becomes desensitized to it.

The second technique is the so-called. flood technique

. It is essentially the opposite of the first: a person is immediately presented with a very high-strength stimulus and waits until he is so sick that he “gets tired of being afraid.”

That, in fact, is the whole essence of CBT. Of course, there are many interesting technical points, but their consideration is clearly beyond the scope of our review article, and instead of going into this jungle, understandable only to professionals, let’s talk a little more about cognition, and then consider an example of working with them.

Types of Cognitive Behavioral Therapy

Cognitive behavioral therapy is considered a family of interventions. Over the years, various types of cognitive behavioral protocols have been developed to better address various disorders, including post-traumatic stress disorder, obsessive-compulsive disorder, and social anxiety disorder.

Each protocol uses different therapeutic methods, although they have common features. The main common thread is the belief that harmful thoughts can lead to emotional distress. Changing unhealthy thoughts reduces psychological pain and destructive behavior.

Types of cognitive behavioral therapy include:

Acceptance and Commitment Therapy : Uses a set of techniques to gain understanding and acceptance of negative emotions and thoughts rather than trying to change them
Cognitive therapy: Emphasizes recognizing and changing problematic thought patterns, emotional reactions and behavior
Dialectical Behavior Therapy: Emphasizes that patients can improve their responses to emotional stimuli by accepting their life problems; exercises contribute to the development of skills that help the patient to accurately observe and describe his thoughts
Mindfulness-based cognitive therapy: Emphasizes the present moment and increasing awareness of how automatic reactions lead to emotional distress; patients are encouraged to gently recognize and accept their thoughts and feelings with an open mind
Multimodal therapy: Focuses on treating seven different aspects of personality, including behavior, affect, sensation, imagery, cognition, interpersonal relationships, drugs, or biology.
Rational Emotional Behavior Therapy: Focuses on transforming irrational views into balanced views to transform dysfunctional emotions and behaviors into functional ones.
Trauma-focused cognitive behavioral therapy: a structured program that focuses on treating single or multiple traumas and their subsequent negative emotions and behaviors

Art therapy

In itself, it is not a separate direction. This is a set of techniques used by psychotherapists of different specializations; they are united by the goal of self-knowledge not through words and conversations with a therapist, but through self-expression in art. The creative process helps to recognize suppressed emotions and express difficult feelings (eg, pain, aggression).

The difference between art therapy and ordinary drawing, singing or acting circles is that the therapist views the fruits of creativity not as something separate, but as a reflection of the client’s personality and his difficulties. The works are not subject to criticism or evaluation, because the main condition of therapy is the acceptance of any constructive self-expression.

How does TOS work?

The principles of cognitive behavioral therapy argue that obstructive thought processes and learned patterns of unhelpful behavior contribute to psychological problems. A person can make positive changes in their life by actively working to understand and change these destructive thoughts and behaviors.

During cognitive behavioral therapy, the patient and therapist work together to understand the patient's difficulties and develop a treatment plan aimed at changing the problematic thoughts, feelings, or behaviors.

Plans to change existing cognitive models include:

Learn to recognize and accept harmful thoughts and emotions
Understanding other people's motives
Gaining Self-Confidence
Learn how to properly cope with stressful situations

Strategies for changing problem behavior include:

Learn to face your fears
Practice how to stay calm in difficult situations

CBT for schizophrenia

CBT methods for schizophrenia rely primarily on behavioral strategies to influence change, with additional emphasis on cognitive components. These forms of CBT for schizophrenia aim to improve psychological adjustment at home, social skills, and improve self-discipline using behavioral strategies. These approaches continue to be used in cases where symptomatic deficits in schizophrenia and improvement of functional skills are the primary focus.

CBT methods are quite broad, effective and very valuable for treating a huge range of mental disorders.

Methods of cognitive behavioral therapy

The range of techniques used during cognitive behavioral therapy include:

Cognitive restructuring: the process of identifying and overcoming negative thoughts and beliefs
Mindfulness: Focus on the present moment while gently accepting feelings and thoughts
Relaxation: visualization, breathing techniques, massage and medications (if necessary)
Problem Solving: Learn to constructively solve everyday problems
Exposure therapy: gradual exposure to scary situations in a safe environment
Role play: acting out situations that cause anxiety while discussing associated harmful thoughts and emotions with a therapist
Homework: reading or writing assignments that reinforce the theme of each therapy session
Skills training: teaching specific social skills, communication skills, and self-confidence that can help a person successfully cope with difficult life situations

What to Expect During a CBT Session

CBT treatment is short-term compared to some other forms of treatment. A cognitive behavioral therapist typically spends the first few sessions assessing the problems or issues causing the client's distress. The client and therapist will then develop a treatment plan and a list of goals for the sessions.

The number of sessions will vary, but can last up to 16 weeks (assuming one session per week). Most CBT sessions last about 60 minutes, depending on the therapist's recommendation. When someone attends a CBT session, there is often an agenda with structure. For example, a therapist may want to focus on specific techniques or skills to break destructive habits and offer healthier alternatives. Cognitive behavioral therapy sessions can be done one-on-one or in a group with other patients or family members.

The person will spend time identifying and analyzing the thoughts, feelings, and circumstances that lead to destructive thoughts. This functional analysis during cognitive behavioral therapy can identify areas where barriers or challenges to coping still exist.

Without identifying and addressing these problems, a person may face a higher risk of future problems. Gradual exposure to fearful situations can also be used during cognitive behavioral therapy sessions to help the client cope with such situations slowly without experiencing negative thoughts or emotions. Homework assignments, which may include reading homework, writing projects, or assignments, are used in conjunction with therapy sessions to enhance the focus of each week.

How are CBT sessions conducted and what techniques are used?

Treatment with a cognitive psychotherapist takes place in the form of 1-2 sessions per week, the total number of which is 20-30 sessions. As I already said, it is very important before the first session that the patient first decides on the goals of psychotherapy. First of all, he must answer the following questions: • What does not suit you in your life, character, relationships and what specifically would you like to change - relationships in the family, work team, with the opposite sex, or maybe you want to find yourself in a new social role or bring back creativity? • What bad habits or addictions would you like to get rid of (for example, gambling addiction) and what useful skills would you like to acquire? All these problems need to be discussed with a psychotherapist at the first session, who will help to specify them and prioritize them. At the same time, he can offer the patient to undergo a series of tests to objectively assess his mental and moral state, the results of which, by comparison, can be used to monitor the effectiveness of the therapy, to determine its tactics and select the optimal CBT techniques in each specific case. The choice of CBT techniques and methods is huge. In addition to those borrowed from behavioral therapy, cognitive therapy techniques are widely used, namely: 1. To identify automatic thoughts: • Recording thoughts when performing necessary and not performing unnecessary actions. Moreover, this should happen in the order in which thoughts arise, which will make it possible to identify their priority in motivating the patient’s actions. Usually the first thought that comes to mind will be the most important. The main efforts of a cognitive psychotherapist should be directed at its correction. • Cognitive rehearsal, associated with the mental playback of negative situations and verbal voicing of emerging automatic thoughts. All results of the experiment are recorded in a separate diary of thoughts, which also records all the thoughts that arise in the patient over several days in order to identify the most significant ones. • Detachment is a kind of abstraction from one’s own thoughts and its objective assessment. Allows you to highlight and realize the spontaneity of bad thoughts, the automatic nature of their occurrence, inherent in previous negative experiences, as well as their non-adaptive nature, i.e. the ability to cause destructive negative emotions.

2. After identifying automatic thoughts, the most difficult work begins: changing them and correcting distortions. To do this, the following methods are used: • Argumentation and counterargumentation with writing down and repeatedly reading the arguments “for” and “against” when an automatic thought appears. With frequent reproduction, the human brain will remember useful arguments and remove “harmful” motives from quick memory. • Speaker technology. It consists of filling out a table with several columns - the first one records the problem, the 2nd - the accompanying feelings and emotions, the 3rd - the automatic thoughts that arise in this case, the 4th - the arguments for them, and the 5th - th – “against”. • Identifying the pros and cons of the problem in the short and long term. • Conducting experiments to test the correctness of judgments. For example, an offer to evaluate a situation without emotion or imagine how other people would react to it. • Discussing past events with witnesses, especially in situations with patients whose memory is distorted or replaced by fantasies, for example, in schizophrenia. The method is also relevant in case of misinterpretation of the behavior and motives of other people. • Imagination. This is especially true for anxious patients, in whom maladjustment is caused not so much by automatic thoughts as by obsessive images. A variety of techniques are used here, including metaphors, poems, parables for greater clarity, commands to oneself to “stop!”, replacing a negative image with a positive one, etc. • Replacement of emotions and revaluation of values. • Appeal to the experience of the psychotherapist himself, statistical data, fiction, etc. 3. At the next stage, they focus on identifying logical errors and contradictions in judgments. The following techniques are most often used here: • Graduality, or scaling, when extreme polarization of judgments using a scale is excluded, i.e. placing them according to the degree of objective reflection of reality. • Reattribution is a review of the patient’s measure of responsibility for his actions in a given situation, which is important for a correct assessment of one’s own contribution and external factors in the development of events. • Exaggeration – taking a certain belief of the patient to extremes or absurdity and thus encouraging it to be re-evaluated.

4. Assessing the likelihood of the worst case scenario allows you to narrow the time frame of the problem and reveal its true significance in the patient’s life: • Decentering, when the patient’s ideas that he is the center of everyone’s attention and that the whole world is aimed against him lead to a state of discomfort and provoke sociopathic thoughts. • Decatastrophization. It is used for various anxiety disorders and forces the patient to think about a realistic assessment of the consequences of the events that worry him. For example, if this does happen, what will happen - will your career be destroyed, or you will die, or your family will abandon you, or will all this last forever? The answers to these questions will allow a person to understand the transitory nature of the problem, and the automatic thought of its infinity will simply disappear. To consolidate the positive effect of CBT, it is important to use exercises such as: • Repetition - repeated repetition of the desired thinking and behavior in practice, and with the consolidation of positive emotions and thoughts. • Together with the psychotherapist, development of a plan for future actions, including conditions and deadlines for implementation, as well as the sequence of actions in the event of extreme or unforeseen situations. And this is not a complete list of techniques used in cognitive behavioral therapy, which are combined into blocks according to specific goals, stages of therapy, nosological forms of mental disorders, as well as the degree of their severity. You can imagine what a colossal arsenal of knowledge, experience and intuition a cognitive psychotherapist must have in order to select the optimal treatment regimen for the patient and adjust it depending on whether progress is achieved or not.

Goals and Benefits

Cognitive behavioral therapy can help people develop coping skills that can be used both immediately and in the future to manage destructive thoughts, emotions and behaviors. Each therapy session can have both short-term and long-term goals tailored to the individual's individual concerns.

By the end of the therapy course, people will be able to better control their behavior, using their new way of thinking to cope with difficult thoughts and feelings. The goal of cognitive behavioral therapy is to resolve problematic thoughts and behaviors, improve functioning, and achieve remission.

After cognitive behavioral therapy, a person can expect a decrease in their symptoms. Coping skills learned through cognitive behavioral therapy may also prevent future episodes of emotional distress. Because CBT focuses on learning practical coping skills, many people see positive results quickly.

For people who have lost the ability to care for themselves, leave a job, or manage their finances, cognitive behavioral therapy can provide valuable tools to rebuild their lives.

Chapter 1. Overview.

The problem of depression.

According to some authoritative sources, at least 12% of the adult population is susceptible to episodic, but quite severe and therefore requiring treatment, depressive disorders (Schuyler, Katz, 1973). Over the past 15 years, hundreds of systematic studies have been conducted related to the biological substrate of depression and the pharmacotherapy of depression. Various publications, coming from both government sources and the private sector, claim that there has been some breakthrough in understanding the psychobiology of depression and the treatment of this disorder with medications.

However, this generally rosy picture leaves clinicians confused. Despite significant advances in the field of pharmacotherapy for depression, this disease is still widespread. Moreover, the number of suicides, which is considered to be an indicator of the prevalence of depression, not only has not decreased, but has increased in recent years. The sustainability of this indicator is especially significant given the enormous impact of efforts to establish and support suicide prevention centers across the country.

The National Institute of Mental Health Special Report on Depressive Disorders (Secunda, Katz, Friedman, 1973) states that depression accounts for 75% of all psychiatric hospitalizations and that 15% of adults aged 18 to 74 years experience depressive symptoms each year. In monetary terms, this state of affairs is estimated by the authors in the range from 3 million to 9 million dollars. And these same authors emphasize that “the main burden of treatment for depressive disorders (75% of all psychiatric hospitalizations) falls on psychosocial therapeutic modalities.”

The importance of psychotherapy in the treatment of depression.

The value of effective psychotherapy for the treatment of depression is self-evident, and our task is to clearly define the indications and contraindications for its use, as well as to establish its role in the overall process of treating a depressed patient. Because psychotherapy is used to some extent and in different forms in the treatment of almost all depressed patients, it is critical to define specific forms of psychotherapy and evaluate their effectiveness so that the consumer knows whether this expensive service is producing beneficial results. However, there are other reasons for defining and testing specific psychotherapeutic modalities.

1. It is clear that drug treatment is much cheaper than psychotherapy, but not all depressed patients respond to antidepressants. The most optimistic estimates from numerous controlled studies in the field of pharmacotherapy for depression are that only 60-65% of patients show significant improvement as a result of the use of conventional tricyclics (see Beck, 1973, p. 86). Therefore, for the 35-40% of depressed patients who do not respond to drug treatment, other methods should be used.

2. Many of the patients who could benefit from drug treatment either refuse to take the medication for personal reasons or stop the course they have started due to the development of side effects.

3. In the long term, drug dependence can indirectly affect the patient's ability to use their own psychological methods to cope with depression. The extensive literature on attribution suggests that patients taking medications typically blame chemical imbalances for their problems and attribute improvements in their condition solely to the effects of the medications (Shapiro & Morris, 1978). As a result, as socio-psychological research shows, the patient is no longer particularly inclined to engage or develop his own coping mechanisms with depression. The relatively high percentage of patients previously treated with medication (approximately 50% in the next year after completion of therapy) may support the above assumption.

Simple common sense tells us that an effective course of psychotherapy may be more beneficial in the long term than pharmacotherapy because the psychotherapeutic experience is educational for the patient.

. The patient develops effective ways to overcome depression, learns to recognize its approach and take the necessary measures, and perhaps even prevent depression.

The fact that suicide rates remain high despite the widespread use of antidepressants suggests that pharmacotherapy, although a temporary solution to a suicidal crisis, does not protect the patient from future suicide attempts. Research shows that the psychological core of the suicidal patient is a feeling of hopelessness (or “generalized negative expectations”). Positive results of working with feelings of hopelessness in depressed patients convince us that cognitive therapy has a more sustainable “anti-suicide effect” compared to pharmacotherapy (see Chapter 10).

Definition of cognitive therapy.

Cognitive therapy is an active, directive, time-limited, structured approach used in the treatment of various psychiatric disorders (eg, depression, anxiety, phobias, pain, 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 (Beck, 1967, 1976). A person’s ideas (verbal or figurative “events” present in his mind) are determined by his attitudes and mental structures (schemas) formed as a result of past experience. For example, the thinking of a person who interprets any event in terms of his own competence or adequacy may be dominated by the following scheme: “Until I achieve perfection in everything, I am a failure.” This scheme determines his reaction to a variety of situations, even those that have nothing to do with his competence.

The therapeutic techniques used in this approach are based on the cognitive model of psychopathology; We are convinced that therapy cannot be effective without a solid theoretical basis. These techniques allow us to identify, analyze and correct the patient's erroneous conceptualizations and dysfunctional beliefs (schemas). The patient learns to solve problems and find ways out of situations that previously seemed insurmountable to him, rethinking them and adjusting his thinking. A cognitive therapist helps the patient think and act more realistically and adaptively, thereby eliminating distressing symptoms.

Cognitive therapy uses a variety of cognitive and behavioral strategies. Cognitive techniques are aimed at identifying and verifying erroneous ideas and maladaptive mental constructs. During therapy, the patient learns to perform highly specific operations, namely: 1) monitor his negative automatic thoughts (ideas); 2) recognize the relationships between one’s own thoughts, emotions and behavior; 3) analyze facts that confirm or refute his ideas; 4) develop more realistic assessments and ideas; 5) identify and modify dysfunctional beliefs that predispose him to distortion of experience.

Various verbal techniques are used to understand what logic is hidden behind the patient’s particular ideas and mental constructs. First, the patient is explained the mechanisms of action of cognitive therapy, after which he is taught to recognize, track and record his negative thoughts in a special “Protocol of Dysfunctional Thoughts” ( Daily
Record of Dysfunctional Thoughts
) (see Appendix). Then the patient, together with the therapist, analyzes the recorded thoughts and experiences to establish the degree of their logic, validity and adaptability and to outline positive patterns of behavior instead of pathological ones. In this way, for example, the patient's tendency to take responsibility for any negative results and the inability to recognize his own achievements are analyzed. Therapy focuses on specific “target symptoms” (eg, suicidal impulses). We identify and then logically and empirically test the thoughts and beliefs that fuel these symptoms (for example, “My life is meaningless and I can’t change anything”).

One of the powerful components of the training model of psychotherapy is that the patient gradually learns many therapeutic techniques from the therapist. At some point, he suddenly finds himself playing the role of a therapist in relation to himself, questioning his own conclusions or predictions. Here are just a few examples of self-questioning that we have seen: On what facts is my conclusion based? Are there other explanations possible? How serious is this loss? Is it taking anything really important out of my life? What's wrong with me if a stranger thinks badly of me? What will I lose if I try to assert my rights more assertively?

Such self-questioning is essential for transferring cognitive techniques from interview situations to everyday situations. It helps the patient break free from stereotypical automatic thinking patterns, a phenomenon that can be called “mindless thinking.”

Behavioral techniques

are used in cases of major depression not only to change behavior, but also to identify associated concepts. Because patients typically require these more active techniques early in treatment, material on behavioral strategies (Chapter 7) will precede the discussion of cognitive techniques (Chapter 8). Examples of behavioral strategies we use include: the Weekly Activity Schedule, where the patient writes hour by hour what he should do in a week, the Mastery and Enjoyment Scale, where he evaluates the completion of tasks presented in the schedule, and Graded Tasks, where the patient is assigned to perform a series of tasks that bring him closer to a goal that seems unattainable to him. In addition, special behavioral tasks are being developed to help the patient check and revise his maladaptive beliefs and ideas.

An important question facing the therapist is what type of intervention should be used and when to use it with a particular patient. As will be discussed in Chapters 7 and 8, both behavioral and cognitive techniques have their own merits and applications in cognitive therapy. It is extremely difficult for a patient who is inhibited and completely absorbed in one idea to engage in introspection, since he is not able to switch his attention from one thing to another. In fact, this procedure may even increase his anxiety and perseveration, while behavioral methods that mobilize the patient to constructive activity are quite a powerful weapon in the fight against inertia. In addition, successful experience in achieving a specific behavioral goal can serve as a more convincing refutation of delusions such as “I am not capable of anything.”

However, while behavioral tasks can more clearly refute erroneous beliefs

patient, cognitive techniques may be the optimal type of intervention when it comes to correcting the patient's inaccurate conclusions about specific events. Imagine a patient who has concluded that her friends do not like her because they have not called her in recent days. It is clear that in this case it is necessary to check the “logical” processes that led the patient to such a conclusion, consider all the facts and develop alternative explanations. A behavioral task will not help solve this cognitive problem.

Without observing these principles, consistent therapy is impossible. As the therapist gains experience, he or she can use a decision tree when conducting therapeutic interviews. Instead of choosing strategies at random, pointing at the sky, so to speak, he chooses the technique that is most appropriate for a specific symptom or specific problem.

As a rule, a course of cognitive therapy consists of 15-25 sessions, with weekly intervals between them. For patients with moderate to severe depression, interviews are typically conducted twice a week for a minimum of 4–5 weeks and then once a week for 10–15 weeks. The patient's final appointments with the therapist as part of a regular course of therapy are usually biweekly, after which we recommend that the patient receive "booster therapy."1 These additional appointments may occur on a regular basis or at the patient's discretion. According to our observations, the average patient comes to the therapist 3-4 times a year after completing the official course of therapy.

New features of cognitive therapy.

What new does this type of psychotherapy bring? Cognitive therapy differs from conventional forms of psychotherapy in two important ways: the structure of the interview and the types of problems it focuses on.

"Collaboration plus empiricism."

A feature of cognitive therapy that distinguishes it from more traditional types of psychotherapy, such as psychoanalysis and client-centered therapy, is the active position of the therapist and his constant desire to cooperate with the patient.
The therapist designs treatment to encourage the patient's participation and cooperation. A depressed patient comes to the therapist confused, distracted and lost in thought, 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 must be resourceful and inventive in order to encourage the patient to actively participate
in various therapeutic operations. We have found that classical psychoanalytic techniques and techniques, such as free association, which requires minimal intervention on the part of the therapist, are not applicable when working with depressed patients, as the patient sinks further into the quagmire of his negative thoughts and ideas.

Unlike psychoanalytic therapy, the content of cognitive therapy is determined by problems “here and now”. We do not attach much importance to the patient's childhood memories unless they help clarify current observations. The main thing for us is to explore what the patient thinks and feels during the session and in between sessions. We are not in the business of interpreting the unconscious. The cognitive therapist, actively interacting and collaborating with the patient, explores his psychological experiences, outlines a plan of action for the patient and gives him homework.

What distinguishes cognitive therapy from behavioral therapy is greater attention to the patient’s internal (mental) experience, thoughts, feelings, desires, fantasies and attitudes. In general, the strategy of cognitive therapy, which distinguishes it from all other therapeutic schools and directions, lies in empirical research

“mechanical” thoughts, conclusions and assumptions of the patient. By formulating the patient's dysfunctional beliefs and ideas about himself, his own experiences, and his own future in the form of hypotheses, we then invite the patient to test the validity of these hypotheses using certain procedures. Almost any internal experience can become the starting point of an experiment to test the patient's negative ideas or beliefs. For example, if a patient believes that others turn away from him with disgust, we help him develop a system of criteria for assessing human reactions and then encourage him to objectively evaluate people's gestures and facial expressions. If the patient is convinced of his inability to perform the simplest hygiene procedures, the therapist can involve him in drawing up a special form in which the patient will subsequently note how well or poorly he performs these procedures.

Cognitive models: a historical perspective.

Cognitive therapy is based on the following general theoretical principles.

1. Perception and experience in general are active

processes involving both objective and introspective data.

2. Concepts and ideas are the result of a synthesis of internal and external stimuli.

3. The products of a person’s cognitive activity (thoughts and images) make it possible to predict how he will evaluate a particular situation.

4. 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.

5. Deformation of the content of basic cognitive structures causes negative changes in a person’s emotional state and behavior.

6. Psychological therapy can help the patient become aware of cognitive distortions.

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

The origins of cognitive therapy can be traced to Stoic philosophy, in particular to the writings of Zeno of Kition (IV century BC), Chrysippus, Cicero, Seneca, Epictetus and Marcus Aurelius. Epictetus wrote in his Manual: “People are upset not by things, but by ideas about things.” Like Stoicism, Eastern philosophies such as Taoism and Buddhism emphasize that ideas are the basis of human emotions. A person can control even the strongest feelings if he changes his ideas.

Freud (1900/1953) also initially believed that unconscious ideas underlie pathological symptoms and affect. Alfred Adler, in his work Individual Psychology, emphasized that in order to understand a patient, one must turn to his conscious experiences. According to Adler, therapy is an attempt to trace how a person perceives and experiences the world. Adler (1931/1958) wrote:

“We do not suffer from mental turmoil - the so-called traumas,

and we extract from them what suits our goals.
We are self-determined
by the meaning we attach to what happened to us; and there is probably something wrong in the fact that we make a separate experience the basis of our future life. Meanings do not depend on situations, but we depend on the meanings we assign to situations.”

Many other authors who came from the school of psychoanalysis or were influenced by the psychoanalytic tradition contributed to the development of cognitive psychotherapy. (For a comprehensive review, see Raimy, 1975.) The most influential names in this series are Alexander (1950), Horney (1950), Saul (1947), and Sullivan (1953).

The philosophical emphasis on conscious subjective experience comes from the work of Kant, Heidegger, and Husserl. This "phenomenological movement" had a significant influence on the development of modern psychology and psychotherapy. Examples of the application of the phenomenological approach to specific pathological conditions are the works of Jaspers (1913/1968), Binswanger (1944-45/1958) and Straus (1966). An equally obvious role in the formation of cognitive psychotherapy was played by psychologists who studied the development of intelligence in children, in particular Piaget (Piaget, 1947/1950, 1932/1960).

Recently, representatives of the behavioral approach have recognized the importance of cognitive formations in the regulation of human activity. Bowers (1973) defended the interactive model of subject-environmental relations and opposed the “situationism” of the classical behavioral school. The growing interest in restructuring cognitive formations, modifying cognitive processes, is reflected in the work of Arnold Lazarus (1972), who states: “The bulk of psychotherapeutic efforts is now concentrated on correcting the patient’s misconceptions.” The latter, Lazarus argues, can either precede or follow behavioral changes.

An increasing number of American psychotherapists are writing about how the therapist can carry out systematic modification of thinking and perception in the course of psychotherapy. Based on his own theory of personality constructs, Kelly (1955) proposes that therapy should be aimed at changing the patient's conscious everyday experiences. If in traditional therapy, where the roles are strictly divided, the patient is asked to proceed from ideas that do not coincide with his everyday experiences, perception of the world and himself, then, taking on the role of a therapist, the patient finds himself alone with his own ideas about himself and his relationships with people. Kelly calls these perceptions "personality constructs."

Berne (1961, 1964) and Frank (1961) added a number of new methods and concepts to therapy aimed at changing the patient's current conscious experience or cognitive formations.

The work of Ellis (1957, 1962, 1971, 1973) became a powerful stimulus in the development of cognitive-behavioral forms of therapy. Ellis believes that the link between the environmental or activating event (AS) and the emotional consequences (EP) is belief (U). His rational-emotive psychotherapy aims to make the patient fully aware of his irrational beliefs and the harmful emotional consequences of these beliefs. Rational-emotive therapy aims to modify basic irrational beliefs. The possibility of using other techniques to familiarize the patient with his beliefs and then modify them is demonstrated in the work of Maultsby (1975).

Recent studies by representatives of the behavioral school (Mahoney, 1974; Meichenbaum, 1977; Goldfried, Davison, 1976; Kazdin, Wilson, 1978) have provided even stronger empirical and theoretical foundations for the development of therapy in this direction.

Cognitive therapy for depression consists of a number of interrelated techniques that have undergone rigorous clinical testing in working with depressed patients. These techniques are applied within a theory that explains the psychological structure of depression (Beck, 1976). As mentioned above, the use of cognitive therapy techniques is impossible without understanding the cognitive model of depression.

Cognitive model of depression.

The cognitive model of depression is the result of systematic clinical observations and experimental research (Beck, 1963, 1964, 1967). It was the combination of clinical and experimental approaches that made it possible to build this theoretical model and formulate the principles of cognitive therapy.

The cognitive model contains three specific concepts that explain the psychological structure of depression: 1) cognitive triad, 2) schemas, and 3) cognitive errors (incorrect information processing).

The effectiveness of cognitive behavioral therapy

Research has shown that cognitive behavioral therapy improves treatment success for a variety of mental disorders in a wide range of people.

In some cases, cognitive behavioral therapy is more effective than other psychotherapeutic approaches. Cognitive behavioral therapy is also successful when used in combination with appropriate medications, helping patients achieve significant symptom reduction.

The use of cognitive behavioral therapy to treat substance use disorders has been growing for over 30 years and is now one of the most widely studied psychosocial interventions for the treatment of drug addiction.

Clinical research consistently shows that coping strategies from cognitive behavioral therapy can improve a patient's chances of achieving long-term recovery. A comparative analysis of 53 clinical studies found that cognitive behavioral therapy was effective in treating a wide range of addictive disorders, including alcoholism, drug abuse, nicotine dependence and many other conditions.

CBT in the treatment of addiction and mental health

Research into the success of cognitive behavioral therapy has shown that cognitive behavioral therapy is effective for treating mental disorders. Cognitive behavioral therapy is used to treat many mental illnesses, including:

Depression
Anxiety disorders
Schizophrenia and other psychotic disorders
Bulimia and other eating disorders
Personality disorders
Bipolar disorder
Post-traumatic stress disorder (PTSD)
Obsessive-compulsive disorder
Substance use disorders
Pregnancy-related disorders
Anger management disorders
Phobias
Insomnia
Attention deficit hyperactivity disorder (ADHD)

Cognitive behavioral therapy can also be used to treat addiction:

marijuana
Alcohol
Cocaine
Amphetamines
Opiates
Other substances

In individual consultations, a therapist may use cognitive behavioral therapy to help a person identify the automatic thoughts that keep them in a cycle of addictive behavior or contribute to their mental health disorder.

In group counseling, people can actively practice their interpersonal skills and cope with their peers. Through relapse prevention training, they can learn to recognize their substance abuse triggers and recognize early warning signs of a potential relapse.

The skills learned in cognitive behavioral therapy offer a practical way to replace destructive thoughts with positive, self-enhancing beliefs. For people in recovery or people with mental disorders who have lost a sense of control over their lives, cognitive behavioral therapy offers hope for freedom from the cycle of destructive behavior.

In the treatment of addiction and mental health disorders, cognitive behavioral therapy provides patients with the following options:

Giving them simple, practical tools to change negative beliefs
Strengthening their confidence and sense of self-determination
Helping them visualize the future in a positive way
Helping them develop stronger, more trusting relationships
Teaching them practical ways to prevent relapse
Helping them develop sober activities to replace substance use

Although cognitive behavioral therapy is an important component of mental health and substance use disorder treatment programs, therapy alone may not be enough to help everyone achieve their recovery goals. Combining cognitive behavioral therapy with other treatment methods can produce even better results than therapy alone.

At Narcohealth, we use cognitive behavioral therapy to help our patients lead healthy and meaningful lives. If you or someone you love is struggling with a substance use disorder, we can provide all the accommodations you need to achieve recovery.

Special techniques

To treat some severe mental disorders, special cognitive therapy techniques are used. They are combined with medications and other types of mental health care. In this way, it is possible to reduce the severity of the symptoms of the disorder and increase the effectiveness of the main treatment.

Among the special methods of cognitive psychotherapy, the most popular are the methods used to treat such pathologies:

Obsessive-compulsive disorder. When correcting this disease, the “four steps” method, developed by American psychiatrist Jeffrey Schwartz, is used. The goal of this treatment method is to change or simplify obsessive thoughts and “rituals” procedures, as a result they are reduced to a minimum. The patient must become aware of his illness and learn to resist its manifestations. The therapist explains to the patient which of his fears are real and which are caused by the disease. They are clearly differentiated, and the patient is shown a model of behavior of a healthy person. Typically, people who represent authority for the patient are chosen as examples. Work in this direction is being carried out in stages, in four steps. This is why the cognitive treatment method for OBD received its name.
Schizophrenia. This type of disorder is incurable, as it is associated with changes in the cerebral cortex. But the use of cognitive and behavioral therapy methods allows people suffering from schizophrenia to accept their illness and learn to smooth out its manifestations. If the patient constantly conducts conversations with otherworldly entities or imaginary images, then the psychotherapist helps him understand that the conversations are not with living people. Gradually, the person with schizophrenia realizes that his interlocutor is a figment of his imagination, as a result of which such conversations are given less importance. Over time, the patient recalls the imagined image from memory less and less often.
Addictions. Alcoholism and drug addiction are also caused by a person's incorrect automatic thoughts. A feature of the cognitive approach to treating these disorders is that the therapist must first talk with the patient about his long-term plans and life priorities. After all, a person’s short-term goals should depend on this. First of all, he needs to explain that the main goal of any living being is survival. All animals and people enjoy things that promote procreation and survival, such as food, sex, etc. Processes that harm life cause negative sensations (hunger, cold or heat). All these sensations are transferred to actions or situations associated with them. But a person suffering from some type of pathological addiction has a new source of pleasure that was not provided for by nature. As a result, the patient becomes unnecessary natural joys, he sets himself the goal of obtaining pleasure through artificial means, which is harmful to his health and survival. The therapist must convince the drug addict or alcoholic that with a certain desire he can achieve the right goals, which will allow him to get rid of depression and a painful return to reality. It is possible to lift your mood in a natural way if you improve the quality of your own life, increase your self-esteem and “rise” in the eyes of others. Psychotherapists draw up a “wish map” for patients with addictions. This is a diagram that indicates the relationship of basic values necessary for survival with instincts and complex summary associations. This card, among other things, indicates exactly how addiction harms long-term plans and prevents you from fully enjoying life. Using this technique, you can save the patient from most harmful habits, for example, gluttony, gambling or Internet addiction.

The effectiveness of cognitive psychotherapy in the treatment of these severe mental disorders is quite high, as confirmed by numerous studies in this area. Cognitive and behavioral therapy can reduce the likelihood of relapse of the disease several times.

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy is useful for a number of mental health conditions and substance use disorders, including (but not limited to):

depression
Anxiety disorders
Alcohol use disorder
Methamphetamine addiction
Eating disorders

Basic principles of CBT

What is the basis of cognitive behavioral psychotherapy?

The main principles of the new thinking will be:

Your experiences are only your personal vision and personal assessment of a specific situation, and not the result of past experience.
You can radically change your assessment of the event and thoughts associated with it.
Your negative beliefs, although they seem plausible, are not the truth. And it is from these beliefs that you experience psychological discomfort.
Your anxious experiences are a pattern of thinking to which you have become accustomed. You have the power to change your way of thinking and check for errors in your usual beliefs.

Types of Cognitive Behavioral Therapy

Types of cognitive behavioral therapy include:

Acceptance and Commitment Therapy : Uses a set of techniques to gain understanding and acceptance of negative emotions and thoughts rather than trying to change them
Cognitive therapy: Emphasizes recognizing and changing problematic thought patterns, emotional reactions and behavior
Dialectical Behavior Therapy: Emphasizes that patients can improve their responses to emotional stimuli by accepting their life problems; exercises contribute to the development of skills that help the patient to accurately observe and describe his thoughts
Mindfulness-based cognitive therapy: Emphasizes the present moment and increasing awareness of how automatic reactions lead to emotional distress; patients are encouraged to gently recognize and accept their thoughts and feelings with an open mind
Multimodal therapy: Focuses on treating seven different aspects of personality, including behavior, affect, sensation, imagery, cognition, interpersonal relationships, drugs, or biology.
Rational Emotional Behavior Therapy: Focuses on transforming irrational views into balanced views to transform dysfunctional emotions and behaviors into functional ones.
Trauma-focused cognitive behavioral therapy: a structured program that focuses on treating single or multiple traumas and their subsequent negative emotions and behaviors

Preface.

The monograph, which opens up a new approach to understanding and psychotherapy of depression, deserves at least a brief story about the history of its creation.

This book represents the result of many years of research and clinical practice. Its birth was made possible thanks to the efforts of many, many people - clinicians, researchers, patients. While I appreciate the contributions of individuals, I also suggest that cognitive therapy itself is a reflection of changes that have been taking place in the behavioral sciences for many years and have only in recent years become a leading trend. However, we cannot yet accurately assess what role the so-called “cognitive revolution in psychology” played in the development of cognitive therapy.

In placing this book in a personal perspective, I would refer the reader to my earlier work, Depression

;
1967), which was the first approximation to the cognitive model and cognitive therapy of depression and other neuroses. My next work, Cognitive Therapy and the Emotional Disorders , published in 1976 , contained
a detailed description of the cognitive aberrations that characterize each of these neuroses, a detailed presentation of the general principles of cognitive therapy, and a more coherent framework for cognitive therapy for depression.

It is not yet entirely clear to me where my formulations regarding cognitive therapy for depression come from. Looking back, I understand that the first guesses were already visible in the undertaking that I undertook in 1956 with the aim of substantiating certain psychoanalytic concepts. I believed in the truth of psychoanalytic formulations, but I experienced a certain “resistance”, perhaps natural for an academic psychologist and psychiatrist who attaches so much importance to empirical data. Believing that it was possible to develop specific techniques, I conducted a series of research projects designed to confirm the correctness of the psychoanalytic understanding of depression. Another, perhaps more compelling, motivation was the desire to understand the psychological configuration of depression in order to develop a regimen of short-term psychotherapy aimed at eliminating focal psychopathology.

Although the first results of my empirical research seemed to confirm the existence of psychodynamic factors of depression, namely retroflective hostility, the expression of which is the “need for suffering,” subsequent experiments brought a number of unexpected discoveries that contradicted this hypothesis, which pushed me to a more critical assessment of psychoanalytic theory depression, and then the entire structure of psychoanalysis. Ultimately, I came to the conclusion that depressed patients do not have a “need to suffer” at all. Experimental data indicated that a depressed patient tends to avoid behavior that could cause rejection or disapproval from others; on the contrary, he strives to be accepted by people and earn their approval. This discrepancy between laboratory data and clinical theory prompted me to reevaluate my beliefs.

Around the same time, I began to realize to my chagrin that the hopes I had placed in psychoanalysis in the early 1950s were in vain: the many years of psychoanalysis that many of my graduate students and colleagues had gone through had not produced any tangible positive results. changes in their behavior and feelings! Moreover, while working with depressed patients, I noticed that therapeutic interventions based on the “retroflective hostility” and “need for suffering” hypotheses often bring nothing but harm to the patient.

Thus, clinical observations, experimental and correlational studies, and ongoing attempts to explain data that contradicted psychoanalytic theory led me to a complete rethinking of the psychopathology of depression and other neurotic disorders. Having discovered that depressed patients did not have a need for suffering, I began to look for other explanations for their behavior, which only “looked” like a need for suffering. I wondered: how else can one explain their relentless self-flagellation, their persistently negative perception of reality, and what seemed to indicate the presence of autohostility, namely, their suicidal desires?

Remembering my impression of the “masochistic” dreams of depressed patients, which, in fact, served as the starting point of my research, I began to look for alternative explanations for the fact that the depressed dreamer constantly sees himself in a dream as a failure - he either loses some valuable thing, or cannot achieve some important goal, or appears flawed, ugly, repulsive. As I listened to patients describe themselves and their experiences, I noticed that they systematically misinterpreted the facts for the worse. These interpretations, similar to the imagery in their dreams, led me to believe that the depressed patient had a distorted perception of reality.

Further systematic research, including the development and testing of new tools, confirmed this hypothesis of mine. We found that depression is characterized by a person's globally pessimistic attitude towards himself, the outside world and his future. As data accumulated confirming the leading role of cognitive distortions in the development of depression, I developed special techniques, based on the use of logic, that make it possible to correct the patient's cognitive distortions and ultimately lead to a reduction in depressive symptoms.

Through several studies, we have added to our knowledge of how depressed patients evaluate their current experiences and their prospects. These experiments showed that, under certain conditions, a series of successfully completed tasks can play a huge role in changing the patient's negative self-concept and thereby eliminating many of the symptoms of depression.

These studies allowed us to supplement the above-described techniques for correcting cognitive distortions with a new and very powerful means, such as conducting experiments designed to test the patient's erroneous or exaggerated pessimistic beliefs, which ultimately significantly expanded the therapeutic process. Patients now have the opportunity to test their pessimistic interpretations and predictions in real life situations. The concept of homework, or “autotherapy” as we later called it, opened up a real opportunity to expand the therapeutic process beyond the therapy sessions.

The development of cognitive therapy was influenced by the behavior movement. Methodological behaviorism, which emphasizes the importance of setting discrete problems and describing specific procedures for solving them, introduced completely new parameters to cognitive therapy (many authors even began to call our approach “cognitive-behavioral therapy”).

This monograph is largely the result of those conferences that were held weekly at the Department of Psychiatry at the University of Pennsylvania, where problems that arose in the treatment of specific patients were discussed: participants shared their experiences with each other and jointly sought ways to solve problems. Numerous suggestions were subsequently summarized in a series of therapeutic manuals, culminating in the present publication. So great is the number of people who contributed to the formation and development of our knowledge that listing even the main names would take up too much space. We are grateful to all the participants in these conferences, and I am sure they understand very well how large a role they played in the appearance of this book.

I would especially like to thank our colleagues who helped us with materials, suggestions and comments in the preparation of therapeutic guidelines that preceded this monograph. Our most active helpers were Marika Kovach, David Burns, Ira German and Stephen Hollon. We are also extremely grateful to Michael Mahoney, who took the trouble to read and edit our manuscript. We also thank Sterling Moorey for his generous assistance in the final stages of the book's preparation.

We consider ourselves obliged to pay a debt of gratitude to Ruth L. Greenberg, who collaborated with us from the beginning to the end of this undertaking. Her contribution to the creation of this book is so great that it is difficult for us to find words to express our gratitude.

Finally, we offer our sincere thanks to typists Lee Fleming, Marilyn Star and Barbara Marinelli.

In conclusion, a few words about “sexist” language. When we talk about “therapist” and “patient,” we use masculine pronouns (“he,” “him”), but this in no way means that we are talking only about men. We have retained the traditional usage solely for the sake of convenience and simplicity.

Aaron T. Beck, May 1979

How does TOS work?

Plans to change existing cognitive models include:

Learn to recognize and accept harmful thoughts and emotions
Understanding other people's motives
Gaining Self-Confidence
Learn how to properly cope with stressful situations

Strategies for changing problem behavior include:

Learn to face your fears
Practice how to stay calm in difficult situations

What are the benefits of CBT?

The most important advantage of using CBT is the sustainable long-term results. After undergoing cognitive behavioral psychotherapy, the patient is able to monitor, diagnose and treat complex conditions himself and becomes his own psychologist, so relapse is practically excluded.

In addition, CBT has a number of other advantages:

high efficiency, proven by many clinical trials;
short-term – usually about 10-15 consultations are required;
provides a high-quality scientific basis, since the approach is based not only on psychology, but also on psychophysiology, neurobiology and other scientific movements;
an action plan that is clear to the patient and therapist;
pursues specific goals and solves specific problems that are discussed at the beginning of the sessions;
recognized at the level of insurance companies, that is, the costs of CBT in some cases are covered through health insurance.

Methods of cognitive behavioral therapy

The range of techniques used during cognitive behavioral therapy include:

Cognitive restructuring: the process of identifying and overcoming negative thoughts and beliefs
Mindfulness: Focus on the present moment while gently accepting feelings and thoughts
Relaxation: visualization, breathing techniques, massage and medications (if necessary)
Problem Solving: Learn to constructively solve everyday problems
Exposure therapy: gradual exposure to scary situations in a safe environment
Role play: acting out situations that cause anxiety while discussing associated harmful thoughts and emotions with a therapist
Homework: reading or writing assignments that reinforce the theme of each therapy session
Skills training: teaching specific social skills, communication skills, and self-confidence that can help a person successfully cope with difficult life situations

What to Expect During a CBT Session

Examples of CBT exercises

Cognitive techniques are divided into several groups. The exercises of the first group are aimed at identifying negative attitudes. For example, keeping a diary of thoughts and then evaluating them. The exercises of the second group are aimed at challenging the identified attitudes. For example, a person might make a list of the pros and cons of a particular attitude. The exercises of the third group are aimed at correcting ideas. For example, by repeating a positive attitude it is possible to weaken the influence of a provoking factor and eliminate a maladaptive stereotype. Exercises of the fourth group are aimed at increasing the effectiveness of therapy, for example, identifying hidden motives for destructive behavior.

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Goals and Benefits

For people who have lost the ability to care for themselves, leave a job, or manage their finances, cognitive behavioral therapy can provide valuable tools to rebuild their lives.