Cognitive Psychotherapy

Cognitive therapy is one of the areas of modern cognitive-behavioral direction in psychotherapy. Cognitive therapy is a model of a short-term, directive, structured, symptom-oriented strategy for activating self-exploration and changes in the cognitive structure of the Self with confirmation of changes at the behavioral level. Beginning — 1950-60, creators — Aaron Beck, Albert Ellis, George Kelly. The cognitive-behavioral direction studies how a person perceives a situation and thinks, helps a person develop a more realistic view of what is happening and hence more adequate behavior, and cognitive therapy helps a client cope with his problems.

The birth of cognitive psychotherapy was prepared by the development of psychological thought in various directions.

Experimental work in cognitive psychology, such as Piaget’s, provided clear scientific principles that could be applied in practice. Even the study of animal behavior showed that it is necessary to take into account their cognitive capabilities in order to understand how they learn.

In addition, there has been a growing awareness that behavioral therapists are unknowingly exploiting the cognitive capabilities of their patients. Desensitization, for example, uses the patient’s willingness and ability to imagine. Also, social skill re-enforcing is not really conditioning, but something more complex: patients are not taught specific responses to stimuli, but a set of strategies needed to cope with situations of fear. It has become clear that the use of imagination, new ways of thinking and the application of strategies involve cognitive processes.

It is no coincidence that cognitive therapy originated and began to develop intensively in the United States. If psychoanalysis was popular in Europe with its pessimism about human capabilities, then in the USA the behavioral approach and the rather optimal ideology of “self-made-man” prevailed: a person who can make himself. There is no doubt that in addition to the “philosophy of optimism”, the impressive achievements of information theory and cybernetics, and somewhat later the integration of the achievements of psychobiology by cognitivism, “fueled” the humanistic pathos of the emerging model of man. In contrast to the “psychoanalytic man” with his helplessness in the face of the powerful forces of the irrational and the unconscious, the model of the “cognizing man” was proclaimed, capable of predicting the future, controlling the present and not turning into a slave of his past.

In addition, the belief in positive changes that a person is able to achieve by restructuring their ways of thinking, thereby changing the subjective picture of the world, contributed to the wide popularity of this trend. Thus, the idea of ​​»reasonable man» was strengthened — researching ways of understanding the world, restructuring them, creating new ideas about the world in which he — active person, not a passive pawn.

Aaron Beck is one of the pioneers and recognized leaders of cognitive therapy. He received his MD in 1946 from Yale University and later became professor of psychiatry at the University of Pennsylvania. A. Beck is the author of numerous publications (books and scientific articles), which detail both the basics of theory and practical recommendations for providing psychotherapeutic assistance in suicidal attempts, a wide range of anxiety-phobic disorders and depression. His fundamental manuals (Cognitive Therapy and the emotional disorders, Cognitive therapy of depression) first saw the light in 1967 and 1979. accordingly, and have since been considered classic works and have been repeatedly reprinted. One of the last works of A. Beck (1990) presented a cognitive approach to the treatment of personality disorders.

Albert Ellis, the author and creator of rational-emotive therapy — RET, has been developing his approach since 1947, in the same year he received his doctorate in clinical psychology from Columbia University (New York). In the same place, in 1959, A. Ellis founded the Institute of Rational-Emotive Therapy, of which he is the executive director to this day. A. Ellis is the author of more than 500 articles and 60 books that reveal the possibilities of using rational-emotive therapy not only in an individual format, but also in sexual, marital and family psychotherapy (see, for example: The Practice of Rational-Emotive Therapy, 1973; Humanistic Psychotherapy: The Rational-Emotive approach, 1973; What is Rational-Emotive Therapy (RET), 1985, etc.).

A. Beck and A. Ellis began their professional practice with the use of psychoanalysis and psychoanalytic forms of therapy; both, having been frustrated in this direction, turned their efforts towards creating a therapeutic system capable of helping clients in a shorter time and more focused on the task of improving their personal and social adaptation by recognizing and correcting maladaptive thought patterns. Unlike A. Beck, A. Ellis was more inclined to consider irrational beliefs not by themselves, but in close connection with the unconscious irrational attitudes of the individual, which he called beliefs.

Supporters of the cognitive-behavioral direction proceeded from the fact that a person builds his behavior on the basis of his ideas about what is happening. The way a person sees himself, people and life depends on his way of thinking, and his thinking depends on how a person was taught to think. When a person uses negative, non-constructive, or even simply erroneous, inadequate thinking, he has erroneous or ineffective ideas, and hence — erroneous or ineffective behavior and the resulting problems. In the cognitive-behavioral direction, a person is not treated, but taught to think better, which gives a better life.

A. Beck wrote about this: “Human thoughts determine his emotions, emotions determine the corresponding behavior, and behavior, in turn, shapes our place in the world around us.” In other words, thoughts shape the world around us. However, the reality that we imagine is very subjective and often has nothing to do with reality. Beck repeatedly said, «It’s not that the world is bad, but how often we see it that way.»

Sadness provoked by the willingness to perceive, conceptualize, interpret what is happening mainly in terms of loss, deprivation something or lesions. In depression, «normal» sadness will be transformed into an all-encompassing feeling of total loss or complete fiasco; the usual desire for a preference for peace of mind will turn into a total avoidance of any emotions, up to the state of «emotional dullness» and emptiness. At the level of behavior, in this case, there are maladaptive reactions of refusal to move towards the goal, a complete refusal of any activity. Anxiety or anger are a response to the perception of the situation as threatening and as a coping strategy for anxiety-phobic disorders, avoidance or aggression towards the “aggressor” most often becomes when emotions are activated anger.

One of the main ideas of cognitive therapy is that our feelings and behavior are determined by our thoughts, almost directly. For example, a person who is at home alone in the evening heard a noise in the next room. If he thinks they are robbers, he may get scared and call the police. If he thinks that someone forgot to close the window, he may get angry at the person who left the window open and go to close the window. That is, the thought that evaluates the event determines emotions and actions. On the other hand, our thoughts are always one or another interpretation of what we see. Any interpretation implies some freedom, and if the client made, let’s say, a negative and problematic interpretation of what happened, then the therapist can offer him, on the contrary, a positive and more constructive interpretation.

Beck called unconstructive thoughts cognitive errors. These include, for example, distorted conclusions that clearly do not reflect reality, as well as exaggeration or understatement of the significance of certain events, personalization (when a person ascribes to himself the significance of events to which, by and large, he has nothing to do) and overgeneralization (on based on one small failure, a person makes a global conclusion for life).

Let us give more specific examples of such cognitive errors.

a) arbitrary inferences — drawing conclusions in the absence of confirming factors or even in the presence of factors that contradict the conclusions (to paraphrase P. Watzlawick: «If you don’t like garlic, then you can’t love me!»);

b) overgeneralization — derivation of general principles of behavior from one or more incidents and their broad application to both appropriate and inappropriate situations, for example, the qualification of a single and particular failure as a «total failure» in psychogenic impotence;

at) selective arbitrary generalizations, or selective abstraction, — understanding what is happening on the basis of taking details out of context while ignoring other, more significant information; selective bias towards negative aspects of experience while ignoring positive ones. For example, patients with anxiety-phobic disorders in the flow of media messages «hear» mainly reports of disasters, global natural disasters or murders;

d) exaggeration or understatement — a distorted assessment of the event, understanding his as more or less important than it really is. Thus, depressed patients tend to underestimate their own successes and achievements, underestimate self-esteem, exaggerating «damages» and «losses». Sometimes this feature is called “asymmetric attribution of luck (failure), which implies a tendency to attribute responsibility for all failures to oneself, and “write off” good luck due to random luck or a happy accident;

d) personalization — seeing events as the results of one’s own efforts in the absence of the latter in reality; the tendency to relate to oneself events that are not really related to the subject (close to egocentric thinking); seeing in the words, statements or actions of other people criticism, insults addressed to oneself; with certain reservations, this can include the phenomenon of “magical thinking” — exaggerated confidence in one’s involvement in any or especially “grand” events or accomplishments, faith in one’s own clairvoyance, and so on;

f) maximalism, dichotomous thinking, or black and white thinking — reckoning an event to one of two poles, for example, absolutely good or absolutely bad events. As one of the patients we observed said: “From the fact that I love myself today, it does not follow that tomorrow I will not hate myself.” .

All these examples of irrational thinking are the field of activity for a cognitive psychotherapist. Using various techniques, he instills in the client the ability to perceive information in a different, positive light.

In summary, the general scheme used in cognitive therapy is:

External events (stimuli) → cognitive system → interpretation (thoughts) → feelings or behavior.

It is important that A. Beck distinguished different types or levels of thinking. First, he singled out arbitrary thoughts: the most superficial, easily realized and controlled. Second, automatic thoughts. As a rule, these are stereotypes imposed on us in the process of growing up and upbringing. Automatic thoughts are distinguished by a kind of reflex, curtailment, conciseness, not subject to conscious control, transience. Subjectively, they are experienced as an indisputable reality, a truth not subject to verification or dispute, according to A. Beck, like the words of parents heard by small and gullible children. And thirdly, basic schemas and cognitive beliefs, that is, the deep level of thinking that occurs in the area of ​​the unconscious, which is the most difficult to change. A person perceives all incoming information at one of these levels (or at all at once), analyzes, draws conclusions and builds his behavior on their basis.

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

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

Steps of cognitive correction:

1) detection, identification of automatic thoughts,

2) definition of the main cognitive theme,

3) recognition of generalized basic beliefs,

4) purposeful change of problematic basic assumptions to more constructive and

5) consolidation of constructive behavioral skills acquired during therapeutic sessions.

Aaron Beck and his co-authors have developed a whole range of techniques aimed at correcting the automatic dysfunctional thoughts of depressed patients. For example, when working with patients who are prone to self-flagellation or taking on excessive responsibility, the technique of reattribution is used. The essence of the technique is to, through an objective analysis of the situation, highlight all the factors that could affect the outcome of events. Exploring fantasies, dreams and spontaneous utterances depressed patients, A. Beck and A. Ellis found three main themes as the content of basic schemes:

1) fixation on a real or imaginary loss — the death of loved ones, the collapse of love, loss of self-esteem;

2) a negative attitude towards oneself, towards the world around, a negative pessimistic assessment of the future;

3) the tyranny of duty, i.e. the presentation of rigid imperatives to oneself, uncompromising demands such as “I must always be the very first” or “I must not allow myself any indulgences”, “I must never ask anyone for anything” and etc.

Homework is of the utmost importance in cognitive therapy. The undoubted advantage of cognitive psychotherapy is its cost-effectiveness. On average, the course of therapy includes 15 sessions: 1-3 weeks — 2 sessions per week, 4-12 weeks — one session per week.

Cognitive therapy is also characterized by high efficiency. Its successful use leads to fewer relapses of depression than the use of drug therapy.

When starting therapy, the client and therapist must agree on what problem they are to work on. It is important that the task is precisely to solve problems, and not to change the personal characteristics or shortcomings of the patient.

Some principles of the work of the therapist and clients were taken by A. Beck from humanistic psychotherapy, namely: the therapist should be empathic, natural, congruent, there should be no directives, client acceptance and Socratic dialogue are welcome.

Curiously, over time, these humanistic requirements were practically removed: it turned out that the straightforward-directive approach in many cases turned out to be more effective than the Platonic-dialogical one.

However, unlike humanistic psychology, where the work was mainly with feelings, in the cognitive approach, the therapist works only with the client’s way of thinking. In dealing with a client’s problems, the therapist has the following goals: to clarify or define problems, to help identify thoughts, images, and sensations, to explore the meaning of events for the client, and to evaluate the consequences of persisting maladaptive thoughts and behaviors.

In place of confused thoughts and feelings, the client should have a clear picture. In the course of work, the therapist teaches the client to think: to refer to the facts more often, to evaluate the probability, to collect information and put it all to the test.

Experience testing is one of the most important points that the client should be accustomed to.

Much of the testing of hypotheses happens outside of the session, during homework. For example, a woman who assumed that her girlfriend did not call her because she was angry called her to check whether her assumption was correct or not. Similarly, a man who thought everyone was watching him in a restaurant later dined there to make sure that others were more busy eating and talking with friends than they were. Finally, a first-year student, in a state of severe anxiety and depression, tried, using the method of paradoxical intention proposed by the therapist, to act contrary to her basic belief «If I can to do something, I should do it” and chose not to pursue the prestige goals she had been pursuing in the first place. This gave her back a sense of self-control and reduced her dysphoria.

If the client says, «Everyone looks at me when I’m walking down the street,» the therapist might suggest, «Try walking down the street and counting how many people have looked at you.» If the client completes this exercise, his opinion on this matter will change.

However, if the client’s belief was in some way beneficial to him, such an «objection» on the part of the therapist is unlikely to seriously work: the client simply will not do the exercise suggested by the therapist and will remain with his previous belief.

One way or another, the client is offered various ways to test his automatic judgments by experience. Sometimes for this it is proposed to find arguments «for» and «against», once the therapist turns to his experience, to fiction and academic literature, statistics. In some cases, the therapist allows himself to «convict» the client, pointing out logical errors and contradictions in his judgments.

In addition to experiential testing, the therapist uses other ways to replace automatic thoughts with measured judgments. The most commonly used here are:

1. Method of reassessment: checking the likelihood of alternative causes of an event. Patients with a syndrome of depression or anxiety often blame themselves for what is happening and even the occurrence of their syndromes («I think wrong, and therefore I am sick»). The patient has the opportunity to make his reactions more in line with reality by reviewing the many factors influencing the situation, or by applying a logical analysis of the facts. A woman with anxiety syndrome sadly explained that she felt nauseous, dizzy, agitated, and weak when she was «anxious.» After checking alternative explanations, she visited a doctor and learned that she was infected with an intestinal virus.

2. Decentralization, or enon-personalization of thinking) is used when working with patients who feel that they are in the center of attention of others and suffer from this, for example, with social phobia. Such patients are always confident in their own vulnerability to the opinions of others about them and are always set to expect negative assessments; they quickly begin to feel ridiculous, rejected, or suspect. A young man habitually thinks that people will think he is stupid if he does not appear to be completely self-confident, on this basis he refuses to go to college. When it came time to apply to an educational institution, he conducted an experiment to determine the true degree of uncertainty. On the day of the submission of documents, he asked several applicants like him about their well-being on the eve of the upcoming exams and the forecast of their own success. He reported that 100% of the applicants were friendly towards him, and many, like him, experienced self-doubt. He also felt satisfied that he could be of service to other applicants.

3. Conscious self-observation. Depressed, anxious and other patients often think that their ailments are controlled by higher levels of consciousness, constantly observing themselves, they understand that the symptoms do not depend on anything, and the attacks have a beginning and an end. Anxiety correction helps the patient to see that even during an attack, his fear has a beginning, a peak and an end. This knowledge maintains patience, breaks down the destructive notion that the worst is about to happen, and reinforces the patient in the idea that he can survive the fear, that the fear is short-lived, and that he simply has to wait out the wave of fear.

4. Decastrophy. For anxiety disorders. Therapist: “Let’s see what would happen if…”, “How long will you experience such negative feelings?”, “What will happen next? You will die? Will the world collapse? Will it ruin your career? Will your loved ones abandon you?» etc. The patient understands that everything has a time frame and the automatic thought “this horror will never end” disappears.

5. Purposeful repetition. Re-enactment of the desired behavior, repeated testing of various positive instructions in practice, which leads to increased self-efficacy.

Methods of work may vary depending on the type of patient’s problems. For example, in anxious patients, not so much «automatic thoughts» as «obsessive images» predominate, that is, it is rather not thinking that maladjusts, but imagination (fantasy). In this case, cognitive therapy uses the following methods to stop inappropriate fantasies:

Termination Technique: Loud command “stop!” — the negative image of the imagination is destroyed.

One of the frequently used and very effective techniques here is constructive imagination. The patient is asked to rank the expected event in steps. Thanks to acting out in the imagination and scaling, the forecast loses its globality, assessments become more gradual, and negative emotions become more accessible to self-control and manageable. In fact, the desensitization mechanism works here: a decrease in sensitivity to disturbing experiences due to their calm and methodical reflection.

In dealing with depressed patients, cognitive therapists work on their basic principle: a person’s feelings and states are determined by his thoughts. Depression occurs when a person begins to think that he is worthless or that no one loves him. If you make his thoughts more realistic and justified, then the person’s well-being improves, depression disappears. A. Beck, observing patients with neurotic depression, drew attention to the fact that in their experiences the themes of defeat, hopelessness and inadequacy constantly sounded. According to his observations, depression develops in people who perceive the world in three negative categories:

1. negative view of the present: no matter what happens, a depressed person focuses on the negative aspects, although life provides some experience that most people enjoy;

2. hopelessness about the future: a depressed patient, drawing the future, sees only gloomy events in it;

3. reduced self-esteem: the depressed patient sees himself as incapable, unworthy and helpless.

To correct these problems, A. Beck compiled a behavioral therapeutic program that uses self-control, role-playing, modeling, homework and other forms of work.

J. Young and A. Beck (1984) point to two types of problems in therapy: difficulties in the relationship between the therapist and the patient and the misuse of techniques. Proponents of CT insist that only those who are not well versed in cognitive therapy can view it as a technique-oriented approach and therefore overlook the importance of the patient-therapist relationship. Although CT is a prescriptive and fairly well structured process, the therapist must remain flexible, ready to deviate from the standard when required, adapting the methodological procedures to the patient’s individuality.