CBT: psychotherapy for geeks

When it comes to psychotherapy, many imagine the legendary couch, the twilight of a cozy office, a wise elderly therapist with a cigar and endless associations: “ You know, yesterday I saw a man with an umbrella on the street, he walked so fast that his umbrella was evenly swaying and it caused I have some vague, vague feelings, he reminded me of my elder brother Ivan, with whom we played the doctor as a child, he, by the way, has become so much like his father! "

Others immediately begin to remember unfavorable (Popper's unscientific), lack of imputed evidence regarding the clinical effectiveness of such conversations, cases of long-term analysis (the psychoanalytic literature describes decades of regular paid meetings), unwillingness to use Occam's razor and other unpleasant things.
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Today I want to talk to you about CBT and show that psychotherapy may very well be different.

Tl; dr : The article tells about the basics of KPT. If you have psychological problems, but you do not believe that they can be solved by talking about how your mother disliked you in childhood, you may like this kind of psychotherapy. It is logical, rational and almost without superfluous entities. And most importantly - focuses on thoughts, not feelings.

Comparison with psychoanalysis

It so happened that, until now, non-specialist psychotherapy as such is often associated with one of its particular areas - psychoanalysis (in the West, by the way, on the contrary - default psychotherapy is CBT). And all the above stereotypes are either generated by them, or relate, for the most part to him (and some derived psychodynamic areas).

So, the first difference between CBT and psychoanalysis is, paradoxically, the name. The first is cognitive-behavioral therapy , i.e. therapy aimed at changing how a person thinks (his thoughts), and how he behaves. The second, as the name implies, claims to work with the psyche in all its complexity and diversity.

The second difference is that a lot of things are postulated in psychoanalysis: the division of the psyche into Eid (“a place where instincts boil, animal desires and impulses”), the Super-Ego (there, according to psychoanalytic ideas, man’s moral attitudes are stored) and the Ego (a structure that is committed to ensuring the interests of the Eid, while respecting the prohibitions of the superego).

The CBT does not tell us anything about how the psyche is “in reality” , it simply works with its observable (externally or by introspection) phenomena.

Psychoanalysis tells us about the libido - some kind of driving energy of the psyche (which no one has ever seen), to which, ostensibly, one can reduce all the motives of human strivings and actions. CPT is looking for specific reasons for each specific case, without seeking to find the ultimate basis.

In psychoanalysis, the emphasis is on the work of the so-called. “Unconscious”, all the causes of neurosis and ways to solve them, from his point of view, lie there: you need to get the client into the unconscious part of the psyche in a roundabout way, release the repressed needs and everything will be OK. What the client thinks at the same time - for the psychoanalyst, it is only interesting to the extent that these thoughts can lead him to ideas about what is happening in the unconscious.

In CBT, the therapist is directly interested in the client's thoughts and believes that it is the thoughts and behavior , rather than semi-mythical unconscious entities, that determine the state of health and the degree of adaptation of the client to the environment.

Psychoanalysis is a fundamentally long-term work method. First you need a long period of establishing rapport, then a transfer to the analyst should develop (the state in which the client allegedly transfers his relationship from early childhood (not always, but most often) to the analyst, for example, tries to get his love, as he did with Mother).

In CBT, simple and clear learning attitudes: the therapist teaches the client to think and act in a healthier and more adaptive way. And the duration of therapeutic contact is recommended to limit, for example, thirty sessions (this is a lot, but much less than with psychoanalysis).

Finally, ideologically, psychoanalysis focuses on what happens in the hypothetical internal structures of the client’s mind, and CPT focuses on how the client manifests itself in the world.

The effectiveness and scope of the CPT

Traditional CBT has limitations in use - it gives the best effect in anxiety disorders and depressions of the neurotic level (a term, by the way, from psychoanalysis), i.e. with relatively mild cases of disturbance. Although, for example, severe psychotic depression, anxiety disorders, eating disorders and even obsessive-compulsive disorders are quite amenable to correction with its help.

Special types of therapy have been developed for working with patients with a greater degree of disturbance, which, however, are close ideologically and, in many ways, are based on it:

1. Young's Schemotherapy - added features from other areas of psychotherapy, in particular, transactional analysis and gestalt;

2. Linehan's dialectic behavioral therapy - the expansion of CBT to work with borderline personality disorder, anger management and a bunch of other interesting things added;

3. Functional and analytical therapy of Kokhlenberg and Tsai - transfer the focus from the cognitive part to the behavioral one;

4. And even the cognitive therapy of Sehall and Williams based on mindfulness is a hell of a mixture of Buddhist practices and CBT;

But we will not consider them in detail in the framework of this article, but rather talk about what data we have regarding the effectiveness of the classical CPT.

The first to come to my mind is the classic Beck article [1], which showed the greater efficacy of CPT as compared with pharmacotherapy (the classic tricyclic imipramine, an analog of amitriptyline well known to the general public, was used).

By the way, a more modern meta-study shows that CPT may be more effective than drug treatment and when working with children and adolescents suffering from obsessive-compulsive disorder [5].

Further, it is possible to recall a rather large review from 2010 [2], in which a higher (compared to other variants of psychotherapy), the effectiveness of QT in anxiety and depressive disorders was shown.

Experts of the French National Institute of Health and Medical Research (INSERM) in their meta-analysis recognized [3] the effectiveness of CBT in the following types of disorders: agoraphobia, panic disorders, generalized anxiety disorder, social phobia, post-traumatic syndrome, obsessive-compulsive disorder, depression (mild forms and depression moderate severity), bipolar affective disorder, schizophrenia (chronic in combination with neuroleptics), borderline personality disorder, avoiding disorder in person and others

It is important to note that CBT is an effective way to deal with anxiety not only in adults, but also in children and adolescents [4].

Another feature of CPT is that it is effective not only in the format of a classical full-time work with a psychotherapist, but also in remote (i.e., via the Internet) provision of therapeutic assistance [6,7].

And the most interesting thing for us: there is evidence [8] that, at least in some cases and situations, CBT can be applied to oneself, without the participation of a therapist. It should be noted here that, unlike classical psychoanalysis (I know that in some psychodynamic schools this is also allowed, but this is not about them), a rather significant (if not most) part of the work is carried out by the client independently, even if it works with a therapist. CPT is not the case when the therapeutic process occurs once an hour once a week, the client has to work very intensively on himself between sessions.

Basics of CBT

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

CPT is based on the assumption that what happens to a person depends to a large extent on how he structures the world. And this is determined by the way of his thinking. In CBT, unlike many other psychotherapeutic approaches, it is postulated that the thoughts of a person evoke emotions , and not vice versa.

The most important role here is played by the so-called. automatic thoughts are, oddly enough, thoughts that appear automatically. Let us explain by example: during the writing of this article, the author had to take a break for several days to solve some household problems. When he found out about this, a whole series of involuntary and, as further analysis showed, destructive thoughts, such as “ I am a loser ”, “ I will fail ,” “ I am thrown out with GeekTimes ” and the like, appeared in his brain.

Automatic thoughts are not always destructive, moreover, they are not always incorrect. But it is necessary to treat them with suspicion - as a rule, they are the creation of the principle of saving resources: the brain is "lazy" to calculate the situation completely and gives the first available decision / judgment. And it often happens that the same brain, if you make it think carefully, will give a completely different assessment or make a completely different decision.

For example, a person who picked up minuses into karma may automatically consider himself to be flawed, but, having thought well, he will understand that he simply expressed a too harsh and erroneous statement (a single mistake does not prove the flawedness of the one who committed it).

A synonym for the term “automatic thought” is the word “ cognition, ” which Beck defined as follows: “Cognition is a thought or a figurative representation that may go unnoticed by you if you do not concentrate on them” [9].

Actually, that part of the CBT, which is cognitive - it is about teaching the client to catch his cognitions, to be aware of them, to check for adequacy and (if necessary) to replace them with more adequate thoughts. Those. argue with yourself. And no, this is by no means schizophrenia, it is part of the therapeutic process for CPT, called the dispute.

Some of the cognitions are contested by the therapist, some (most of them must be said) by the client himself.

But in KPT there is also the second part - behavioral. A directive approach works here when the therapist forces the client to behave in a healthy way, for example, a depressed client who is in bed most of the day will be assigned a task of drawing up (and then execution) of a certain daily routine that includes a certain level of activity, and the client with agoraphobia (after appropriate preparation, of course) they will make people visit crowded places.

By the way about the "appropriate training." Within the framework of behaviorism (on which the behavioral part of the CBT is built), various techniques are possible, but two of them deserve special attention and inclusion in this article.

The first is with ismatic desensitization . Especially good for all sorts of phobias. At the first stage, the client is taught some kind of relaxation technique (muscle relaxation, breathing exercises, etc.), after which a fear stimulus is presented to him.

If we imagine that our hypothetical client is afraid of spiders, then he will be shown a photograph of the spider and asked to use the previously learned technique for relaxation. When the photo ceases to make an impression, he will be shown a spider in the bank at a substantial distance and asked to relax. As the therapy progresses, the stimulus will increase until the client loses sensitivity to it.

The second technique is so-called. flood technique . It is fundamentally the opposite of the first: a stimulus of a very high power is immediately presented to a person and they wait until he is so strongly punctured that he “gets tired of being afraid”.

That is, in fact, the whole essence of KPT. Of course, there are many interesting technical issues, 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 cognitions, and then consider an example of working with them.

Cognitive errors

Cognitive errors are what makes our cognitions wrong. Again, not every cognition is wrong, but those that are not wrong are of no interest to us and, accordingly, will not be considered.

Here are some common cognitive errors. Firstly, it is, of course, a catastrophisation , which consists in the fact that the subject, on the basis of one unsuccessful experience, concludes that “ everything is bad and we will all die ”. For example, a student who did not pass one exam at a session may not think about how to get a retake, but to draw a terrible future for himself, where he will be recruited into the army, he will go to war, they will take him prisoner, etc. Such thoughts will be completely disorganizing and obviously will not help out of the situation.

The second interesting and common mistake is excessive generalization (supergeneralization). In this case, the person, ignoring the knowledge gained in the courses of the terver and the matstat, makes assumptions about the general population from one fact. And this set often turns out (in his head, of course) hostile, unpleasant and in every way threatening the subject. The programmer testers have found one uncritical bug, and he is already thinking about leaving the profession, because he was bylokloder and bug-making - this is what it is.

One of my favorite cognitive errors is the so-called. “ Tyranny of being committed, ” which is based on three pillars: “ I owe ,” “ they owe me ,” “the whole world owes me .” Consider examples to make it clearer.

Enikeyschik in the company regularly participates in the inventory of goods, even when there is no direct order of the director, but there is only the insistent demand of the head of the logistics department. Why? Because he feels that he should do it, although in reality there is no relationship of obligation: it is not spelled out in the contract, there is no executive order, there is only cognitive distortion: “ I must, otherwise they will be fired ”.

Another example: the subject requires something that was not agreed upon. The mother requires her son to enter the specialty chosen by her (“ you must become a doctor ”), the head of the department requires cleaning the office space from a subordinate, being very surprised and indignant that the latter did not think of it himself. "But this is elementary, he should have known!"

An example of the third type of involvement: the girl is experiencing the strongest distress from the fact that the bus arrived at the stop is not the route that she needs (“ How is it, everything should be in my opinion! ”).

Examples may seem exaggerated, but they are all taken from real life, and none of them is made-up. By the way, if you have not read the article on Wikipedia about cognitive distortion , I recommend.

How is work with the therapist

Imagine that you wanted to try KPT on yourself. How will it look like? First, you will search and choose a therapist (a separate and rather voluminous topic), then enter into a therapeutic contract with him and, possibly, a contract for changes, after which, in fact, the main work will begin.

Beck himself wrote that the therapist should teach the client to solve the following tasks [9]:

1) track your negative automatic thoughts (views); 2) recognize the relationship between their own thoughts, emotions and behavior; 3) to analyze the facts confirming or refuting his views; 4) develop more realistic assessments and presentations; 5) identify and modify dysfunctional beliefs that predispose him to distort experience.

First, the client will be told about cognition, after which a certain amount of time will be spent on the practice of tracking them and determining their effect on the emotional background and behavior.

Then the most interesting will begin - an assessment of the adequacy of cognitions and what is called a “dispute” in CPT - challenging inadequate and destructive automatic thoughts.

This can be done in different ways: bring a proof for scientific research, find logical contradictions in the client's conclusions, and conduct an experiment. The experiment , in the author's opinion, is the most powerful technique. So, for example, if a person is afraid to defend his rights and even just express his opinion in a team, believing that everyone will immediately turn away from him, then the opposite behavior may be suggested as an experimental one.

Often, the results of the experiment are so much different for the better from the client's expectations that the latter accepts the experimental model of behavior as the main one. So, for example, one girl who was afraid to defend her opinion, not only did not lose her position in the team, but also managed to gain a higher position in the informal hierarchy, significantly reducing the background level of frustration.

What does a dispute look like without experiment? I will give an example from my own therapy:


Here I could not cope without pharmacotherapy, but still it was an important step towards recovery.

The second situation is not complicated by pharmacology:


Actually, the compilation of such (or similar) plates will have to be dealt with by the reader if he decides to work along the lines of the CPT.

It is believed [9] that in the process the brain is trained, and over time, inadequate and destructive automatic thoughts will be replaced by more adequate and constructive ones. Clinical proofs of the effectiveness of this technique are given above.

Of course, KPT is not limited to the elementary techniques cited here - there are both identifying and working out deep-seated destructive installations, and working with managing aggression, and many other things, but we will consider all this in the following articles if the topic itself turns out to be interesting to the community.

Literature

1. Augustus J. Rush, Aaron T. Beck, Maria Kovacs, Steven Hollon. Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research. March 1977, Volume 1, Issue 1, pp 17–37

2. David F. Tolin. s cognitive – behavioral therapy more effective than other therapies ?: A meta-analytic review. Clinical Psychology Review. Volume 30, Issue 6, August 2010, Pages 710–720

3. INSERM Collective Expertise Center. INSERM Collective Expert Reports [Internet]. Paris: Institut national de la santé et de la recherche médicale; 2000-. Psychotherapy: Three approaches. 2004. Available from: www.ncbi.nlm.nih.gov/books/NBK7123

4. Cochrane evidence. Cognitive behavioral therapy for children in children and young people.
www.cochrane.org/CD004690/DEPRESSN_cognitive-behavioural-therapy-for-anxiety-in-children-and-young-people

5. Cochrane evidence. Behavioural and cognitive-behavioral disorder for children and adolescents.
www.cochrane.org/CD004856/DEPRESSN_behavioural-and-cognitive-behavioural-therapy-for-obsessive-compulsive-disorder-ocd-in-children-and-adolescents

6. Cochrane evidence. Internet-based cognitive behavioral therapy with therapist support for anxiety in adults: a review of the evidence.
www.cochrane.org/CD011565/DEPRESSN_internet-based-cognitive-behavioural-therapy-therapist-support-anxiety-adults-review-evidence

7. Cuijpers, P., van Straten, A. & Andersson, G. J Behav Med (2008) 31: 169. doi: 10.1007 / s10865-007-9144-1

8. A Randomized Controlled Trial of Self-Directed Versus Therapist-Directed Disorder Behavior Therapy, Volume 38, Issue 2, Pages 179-191
David F. Tolin, Scott Hannan, Nicholas Maltby, Gretchen J. Diefenbach, Patrick Worhunsky, Robert E. Brady

9. A. Beck, A. Freeman. Cognitive depression therapy.