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Cognitive behavioral psychotherapy. Eating disorders: how to get rid of anorexia and bulimia Anorexia nervosa psychotherapy

Among the various methods of treating anorexia, psychotherapy is the main one. Of course, using various medications and procedures, it is possible to eliminate the negative consequences of the disease and, thanks to a diet, restore the patient’s weight. However, if the patient does not change his attitude towards the process of nutrition, towards himself, his own weight and figure, then there will be no positive result. After stopping the course of treatment, the disease is likely to return.

Mainly used in the treatment of anorexia cognitive behavioral psychotherapy, which is aimed at making the patient aware of his current condition and identifying the most significant goals, among which recovery should be. For anorexia, such therapy is designed to change the patient's eating behavior.

Initially cognitive behavioral psychotherapy for anorexia was aimed only at restoring in the patient's consciousness conditioned reflex: eat when hungry. Typically, such psychotherapy was carried out in a hospital setting. During treatment, the patient gained weight, but after discharge from the hospital, a relapse occurred, and the patient began to lose weight again.

Much more effective is cognitive behavioral therapy, aimed at correcting the patient’s misconceptions about his own weight, body and shape. The return of a normal and healthy assessment of appearance and body weight leads to the fact that the patient no longer needs to lose weight. He objectively assesses his weight, figure, appearance, accepts himself as he is. During therapy, obsessive ideas about losing weight and fear of being overweight disappear. The patient begins to eat food and gradually gains weight, and then with the help of other treatment methods the effects of anorexia are eliminated. All this happens, of course, under the constant supervision of a doctor.

Psychotherapy also allows you to get rid of the “avoidance” syndrome, when the patient deliberately avoids situations that he considers dangerous. The person self-isolates, which does not contribute to recovery at all. Psychotherapy should be aimed not only at eliminating the symptoms of anorexia, but also at returning the patient to a full life: to his interests, hobbies, hobbies.

An essential component of psychotherapeutic measures for anorexia is family psychotherapy. It is especially important in the treatment of anorexia in adolescents. Family psychotherapy is aimed at correcting stereotypes in relationships between family members. Often the reason for the development of the disease in a teenager is the behavior of the parents: they are constantly dissatisfied with their child, try to impose their opinion on him, and do not respect his interests. The teenager begins to look at himself negatively, which leads to the development of anorexia. Family therapy teaches family members to respect each other's opinions and helps improve the atmosphere in the family. The psychotherapist will explain to parents how to behave with their child during rehabilitation. Family psychotherapy can be carried out either with the participation of the whole family or in pairs (child and father, child and mother, parents only).

Among other psychotherapeutic methods for treating anorexia, body-oriented therapy And mirror baths. A patient with anorexia, together with a psychotherapist, is in a special room among the mirrors, where he studies his naked body, records his feelings, both emotional and physical. This is followed by a discussion of the information received with a psychotherapist. This therapy helps the patient cope with negative attitudes towards their own body.

It is worth distinguishing psychotherapy from nutrition counseling. Unfortunately, only knowledge about proper nutrition will not help get rid of anorexia, since the problem lies much deeper than just eating disorders. Nutrition counseling can be a good complement to psychotherapy.

Despite the fact that psychotherapy is the main method of treating anorexia, it still cannot be carried out outside the general range of therapeutic measures. The most effective results are obtained by: psychotherapy, instrumental and drug treatment.

At the Mental Health Clinic, psychotherapy for anorexia is usually carried out in sessions, since several sessions of psychotherapy are not enough for complete recovery. At the same time, it is very important that the patient works on himself independently, so the psychotherapist can give patients homework. We provide psychotherapy for anorexia both on an outpatient basis and in our country hospital.

Today I’m going to talk about the two main types of eating disorders: anorexia and bulimia, some of the nuances of their occurrence, all sorts of interesting numbers, and how you can cope with them. In general, the formation of anorexia and bulimia occurs easily. It is much more difficult and expensive to get rid of them later. I will tell you briefly, because everything that has been studied and written about these disorders cannot be summarized in one article. If you suspect that you have an eating disorder, then look for symptoms of anorexia and bulimia.

I want to say right away for meticulous readers - and this is correct! - I do not have a single “unfounded” statement: all statistics and other figures used in the article are taken from the published Not literature on the Internet, namely from books and official booklets published respected institutions. A list of references is attached at the end of the article.

Types of Eating Disorders

Eating disorders vary widely in severity and complexity, but two types stand out among them:

  • bulimia nervosa
  • anorexia nervosa

Quite simply, bulimia- this is when a person has the so-called “binge episodes,” during which he eats an abnormally large amount of food; and after this attack, the person induces vomiting or uses laxatives in order to control weight and figure (although not always). Anorexia- this is when a person purposefully loses weight to the point of exhaustion and continues to consider himself “full”, “fat”. It happens when they are combined.

It is completely wrong to believe that the causes of these disorders are some kind of spoiledness, bad manners, weakness of will, “no one cooked them something tasty”, “if only they could at least once try a real Kiev cutlet...”, “we need to throw out the scales, yes and that’s all,” and so on. Unfortunately, everything is not that simple. Not at all like that.

These disorders are believed to only occur in women. No, that's not true either. The vast majority of people with anorexia or bulimia are women (up to 90%). And the remaining 10% are men.

Take a look at the chart: men are much more dissatisfied with their figure than women!

Minnesota experiment

American researchers from the University of Minnesota, USA, under the guidance of nutritionist and physiologist Ancel Keys, conducted the so-called. "Minnesota Fasting Experiment", the results of which revolutionized the understanding of the influence of nutrition on the human psyche and on his physical health. This experiment involved about 40 specially selected and tested healthy men in at different ages. The experiment consisted of 3 stages:

  • 3 months - normal nutrition and detailed analysis and recording of all manifestations, behavior, mood, etc.
  • 6 months - food is reduced by half from the minimum required to maintain the weight of the participants. Recording all changes.
  • 3 months - normal nutrition again.

The experiment had a huge impact on everyone involved, on the study of nutrition and on the psychology of eating behavior. There were both psychological and physiological consequences for the participants. We'll leave physiology for next time and concentrate on psychology.

Although there were significant differences between participants' individual experiences, overall, all male participants experienced dramatic physical, psychological and social changes as a result of food restriction. And besides, for many of them, negative consequences continued even after their weight has returned to its original level, and the experiment ended long ago.

One of the most impressive results of the Minnesota experiment was that all participants changed their attitude towards food. All noted that they found it difficult to concentrate on normal things and that they were constantly worried about thoughts about food and nutrition. Food became the main, if not the main, topic of their conversations, reading, dreams and dreams.

Some men became interested in cooking and began collecting recipes, while others became interested in kitchen tools. One participant in the experiment once found himself rummaging through a trash can to find something for his collection of kitchen tools. And, although most of the men before the experiment were not at all interested in cooking and gastronomy, after the experiment 40% of them reported that they plan to include food and its preparation in their future life plans. Some former participants in the experiment subsequently changed their career completely: they began working in the food industry.

Most had serious psychological problems, incl.. One of the participants, being in some kind of “uncontrolled” state, amputated 3 fingers on his hand, and could not say whether he did it accidentally or intentionally. Other emotional problems included increased irritability, periodic outbursts of anger, a sharp increase. Some started smoking or biting their nails. Some people stopped taking care of their hygiene. Many had problems with thinking: concentration of attention, understanding, and ability to make decisions decreased. All participants, who previously spent 15-20 minutes eating, now sat over the plate for 1.5-2 hours, trying to make up for the lack of food with spices, tea, coffee and... chewing gum.

Almost all participants sexual interest has decreased significantly, and also began to be observed communication problems. Some began to limit their communication with other people. Friendship, humor, plans for life, participation in some groups - all this faded into the background.

Some participants developed bulimic behavior - "binging and purging" - accompanied by very low mood, nausea and negative emotions such as self-loathing.

Within about a year after the end of the experiment, most returned to a normal diet. However, some, unfortunately, were never able to do this.

And all this as a result of food restrictions only half within 6 months. Many people currently suffering from anorexia and bulimia may limit themselves more than half within a few years. And you say, “show him the cutlet and throw away the scales.”

Now, after such horrors, we move on to the current state of affairs. There will be no more horror stories, although it would take a very long time to list them all possible consequences both from the physical and psychological sides.

So what is bulimia?

There are studies that from 1% to 4% All women will one way or another encounter bulimia or its manifestations in their lives. Bulimia is an eating disorder in which a person first eats a huge amount of food in fits and starts, after which he resorts to either laxatives or induces vomiting in order to control his weight. Initially, the weight of such people was either normal or slightly increased.

For example, during an attack of bulimia (about an hour), a woman, a housewife who is not overweight and of average height, can eat:

  • 2 boxes of chocolates
  • half a pack of cookies
  • a glass of milk
  • twelve sandwiches with butter
  • two bananas
  • one ice cream
  • one jar of yogurt
  • one pack of homemade cheese

Some professional areas can provoke a person to develop bulimia or anorexia: ballet, running, figure skating, modeling, gymnastics, bodybuilding, etc. That is, activities in which success is assessed based on body shape, figure and weight.

According to research, Cognitive behavioral therapy is the most effective way for getting rid of bulimia compared to other psychological interventions, and is better than pharmacotherapy (medicines) - cognitive behavioral therapy reduces the incidence of bulimia attacks by up to 85% (in those who have undergone therapy). In addition, CBT reduces the risk of relapse.

There is a 2019 protocol called . It is only suitable for those whose BMI is above 18 or a little lower. It should be very effective, but I can’t say anything yet - in my experience there is not enough for conclusions.

40% of patients are completely cured—they stop overeating and vomiting altogether. About 40% of patients show moderate results. However, within 10 years after the end of treatment, 89% of sufferers recover either completely or partially (17%) - this is due to the delayed effects of therapy, as well as the fact that patients begin to apply the methods in practice with greater success.

On average, a course of therapy for bulimia takes 4 to 5 months and includes 15 to 20 meetings with a psychotherapist.

A CBT-T mentioned above includes only 10 meetings maximum- provided that the client has successfully completed the first 4, then you can extend further. If he fails, it means it doesn’t work for him. The risk is higher, but there are also more benefits, both in terms of time, and in terms of money, and in terms of motivation.

How does it go with bulimia:

  • weight monitoring;
  • regulation of nutrition, intervals and volumes of food;
  • introduction of “forbidden foods” in order to prevent “bouts of gluttony”;
  • learning specific ways to cope with problems;
  • addressing dysfunctional beliefs about weight, shape, self, and body concept;
  • if necessary, therapy for associated problems (usually);
  • if necessary, consultations with other specialists: nutritionist, psychiatrist, therapist, etc.
  • special training aimed at preventing relapses - because, unfortunately, this happens regardless of what therapy has been completed.

What is anorexia?

Anorexia is a disease that leaves people extremely malnourished and yet convinced that they still have excess weight. The American Psychiatric Association estimates that on average 0.5 to 3.7% of all women will experience anorexia in their lifetime. In 90-95% of all cases of anorexia, the sufferers are women. As a rule, anorexia begins in adolescence from the fact that a girl who is slightly overweight or normal weight goes on a diet. Anorexia is a threat to life and health: up to 10% of those suffering from anorexia unfortunately die.

The causes of anorexia can be different:

  • social pressure,
  • "beauty standards"
  • family environment,
  • stressful situations
  • cognitive disorders,
  • biological factors (set weight, hypothalamic activity), etc.

The claim that diet alone causes anorexia is incorrect: most people who diet do not suffer from anorexia. However, in adolescent girls who strictly restrict themselves in nutrition, the likelihood of developing such a disorder during a year of strict diet increases by 18 times. A study was conducted in the USA that showed that anorexia is a disease of “white” women; African-American women have significantly different “ideals.” female beauty"and significantly higher satisfaction with their appearance.

At least half of those suffering from anorexia adhere to the “limiting food consumption” behavior model, that is, they have a clear list of foods that they do not consume: snacks, sweets, side dishes, flour, etc.

The main goal of anorexics is to lose weight. But at the same time, it is always based on fear: giving in to the desire to eat, becoming obese, losing control over weight. At the same time, being already objectively exhausted, depriving their body of important nutrients, these people, unfortunately, continue to follow their diet, becoming more and more concerned about the issue of nutrition.

Anorexia sufferers have various psychological problems. Anorexia is often accompanied by depression, low self-esteem, thoughts and assessments of oneself do not correspond to reality. Eating disorder sufferers also inaccurately perceive their body's internal signals: When anxious or upset, people with anorexia or bulimia often mistakenly think they are hungry - and react in the way they usually react to hunger - that is, by starting to eat. Take a look at the results of this interesting study conducted in the US in the 90s:

(Rebert, Stanton & Schwartz, 1991)

When do people eat junk food? Obviously, when they feel bad. People who experience positive emotions are more likely to eat normal food.

Along with behavioral therapy individual psychotherapy should be carried out. The literature describes a wide range of psychotherapeutic methods - from psychoanalytic to cognitive behavioral therapy. In older adolescence, psychodynamic therapy is especially indicated, which puts the current conflicts of this period of life, considered from the perspective of the biography and family history of the patient, at the center of therapeutic conversations.

Goal of therapy most often - to eliminate the patient’s sense of inferiority, increase self-esteem, and teach how to discuss conflicts that arise in the family. Further problems may be the processing of an increased desire for achievement, leading to restrictions in other areas not related to achieving success, an inability to view relationships other than from a competitive point of view, and pronounced perfectionistic attitudes that push aside all other areas of life. There are various kinds of expressed fears related to the sexual sphere, as well as difficulties in accepting the female role.

Feeling your own inability and insufficiency leads to the fact that autonomy and identity can only be expressed through rigidity and control over one's own body. In the process of psychodynamically oriented therapy, they try, together with the patient, to understand the way in which painful ideas arise, analyze their function in the clinical picture of the disease, and develop an alternative way of thinking and behavior. It should be borne in mind that the ability for retrospective observation is initially limited by the characteristics of adolescence.

Therapy should definitely be focused on current problems female patients; The point of application is not “looking into the mirror of the past,” but rather overcoming difficulties and opening up real paths for further development for the patient.

Cognitive models of psychotherapy for anorexia nervosa

Often in progress development sharply expressed, difficult to correct dysfunctional thoughts and beliefs arise that require targeted influence. Cognitive methods of psychotherapy have proven themselves in cases of pronounced tendencies towards a chronic course of the disease; however, they are also applicable for short-term therapy.

In the center cognitive therapy Dysfunctional ideas about appearance, nutrition and weight are addressed. Her methods are also suitable for the treatment of low self-esteem, feelings of inferiority, as well as deficient self-perception (Steinhausen).

From point of view behavioral analysis symptoms of anorexia are supported and enhanced by cognitive mechanisms: weight loss as a result of fasting means cognitive reinforcement of this behavior, as it convinces the patient of the effectiveness of her behavior and of her own independence and competence. A question from one of the patients: “What will remain for me if I give up fasting?” - puts this problem in the spotlight. An important point of application of therapy is the impaired self-concept of those suffering from anorexia. An excess of negative attitudes at the level of emotions, ideas about oneself and one’s own capabilities occurs regularly and, as with depression, is quite amenable to the influence of cognitive therapy (Beck).

Cognitive therapy V in this case pursues the following goals (Steinhausen): the patient must learn to register her own thoughts and make their perception clearer. She must be aware of the relationships between certain dysfunctional thoughts, abnormal behaviors and emotions, analyze her beliefs and check their correctness, form realistic and adequate interpretations and gradually modify incorrect beliefs.

An illustrative example of psychotherapy for anorexia nervosa

Many patients with anorexia They say: “Everyone thinks that thin people are more attractive and luckier.” This statement is tested in therapeutic conversation. The following questions are being asked.
Do most people really think thin people are more interesting?
Is there a linear relationship here - the less a person weighs, the more attractive he is?
Do all people share such views or only those who uncritically perceive fashion trends?
When using the words “interesting,” “desirable,” or “lucky,” do most people also think about being thin?

Such conversation makes the patient think about the problem of the ideal of thinness, about the correct perception of her body, about the female role and the meaning of physical attractiveness.

Family interventions for anorexia nervosa

Impact on family and environment are part of the standard repertoire of techniques used in the treatment of almost every patient with anorexia nervosa. Of course, explaining this disease solely as a symptom of obligate family dysfunction has proven insufficient (Vandereycken, Kog, Vandereycken). Activities aimed at the patient must be coordinated in time and content with interventions aimed at the family and environment. The drawing gives an idea of ​​the therapy process.

Parallel to patient-centered diagnostics, carried out simultaneously from the very beginning family diagnosis. The basis for further family-oriented work is detailed information to parents regarding the nature of the disease and the planned stages of therapy, as shown in the figure. Further family therapy has two main aspects: first of all, structured psychoeducational techniques are used with an emphasis on the way family members interact with each other and with the patient. Here, the point of application and the subject of discussion is information about the family obtained during this phase of inpatient treatment.

This therapeutic phase transitions into family therapy, " relationship-oriented" Her task is to clarify conflicts between the patient and parents. Data obtained from individual therapy can be used here. Thus, individual and family therapy are closely related to each other. During the outpatient observation phase, this dynamic of therapy is maintained, i.e., if possible, one conversational psychotherapy session per week, one family session per month.

There are very few controls research, empirically proving the effectiveness of family therapy for anorexia nervosa. Russell et al. (Russell et al.) note that family therapy is especially effective when treating young patients whose disease has not yet become chronic. Family therapy as the only method of treatment is indicated only for young patients who have become ill relatively recently. The prerequisites for this are the absence of severe family anomalies and the parents' attitude towards cooperation in the treatment process (Hall).

However, family connection- even if family therapy is not chosen as the main method - it is mandatory in the treatment of every patient with anorexia and has the same great importance, as well as patient-centered interventions. Family-oriented methods for the treatment of anorexia contain elements of counseling, structuring the environment and clarification of relationships between family members.

The first experience of using behavioral therapy was based on the theoretical principles of I. P. Pavlov ( classical conditioning) and Skinner (Skinner V.F.), ( operant conditioning).

As new generations of physicians applied behavioral techniques, it became clear that a number of patient problems were much more complex than previously reported. Conditioning did not adequately explain the complex process of socialization and learning. Interest in self-control and self-regulation within the framework of behavioral psychotherapy has brought closer “ environmental determinism“(a person’s life is determined primarily by his external environment) to reciprocal determinism (a person is not a passive product of the environment, but an active participant in his development).

Publication of the article " Psychotherapy as a learning process” in 1961 by Bandura A. and his subsequent work were an event for psychotherapists seeking more integrative approaches. Bandura presented in them theoretical generalizations of the mechanisms of operant and classical learning and at the same time emphasized the importance of cognitive processes in the regulation of behavior.

The conditioning model of human behavior has given way to a theory based on cognitive processes. This trend was evident in Wolpe J.'s reinterpretation of systematic desensitization as a counterconditioning technique in terms of cognitive processes such as expectancy, coping strategy, and imagination, which led to such specific areas of therapy as covert modeling (Cautela J., 1971 ), skills and abilities training. Currently, there are at least 10 areas of psychotherapy that emphasize cognitive learning and emphasize the importance of one or another cognitive component.

Principles of cognitive behavioral psychotherapy

  1. Many symptoms and behavioral problems are the result of gaps in training, education and upbringing. To help a patient change maladaptive behavior, the psychotherapist must know how the patient's psychosocial development took place, see violations of the family structure and various forms of communication. This method is highly individualized for each patient and family. Thus, a patient with a personality disorder exhibits highly developed or underdeveloped behavioral strategies (for example, control or responsibility), monotonous affects predominate (for example, rarely expressed anger in a passive-aggressive person), and at the cognitive level rigid and generalized attitudes in regarding many situations. Since childhood, these patients have been recording dysfunctional patterns of perception of themselves, the world around them and the future, reinforced by their parents. The therapist needs to examine the family history and understand what is maintaining the patient's behavior in a dysfunctional manner. Unlike patients diagnosed with axis 1, it is more difficult for individuals with personality disorders to form a “benign” alternative cognitive system.
  2. There are close relationships between behavior and environment. Deviations in normal functioning are maintained primarily by reinforcement of random events in the environment (for example, a child's parenting style). Identifying the source of disturbances (stimuli) is an important stage of the method. This requires functional analysis, that is, a detailed study of behavior, as well as thoughts and responses in problem situations.
  3. Behavioral disorders are quasi-satisfaction of basic needs for security, belonging, achievement, freedom.
  4. Behavior modeling is both an educational and psychotherapeutic process. Cognitive-behavioral psychotherapy uses the achievements, methods and techniques of classical and operant learning models, cognitive learning and self-regulation of behavior.
  5. The patient's behavior, on the one hand, and his thoughts, feelings and their consequences, on the other, have a mutual influence on each other. Cognitive is not the primary source or cause of maladaptive behavior. The patient's thoughts influence his feelings to the same extent as feelings influence his thoughts. Thought processes and emotions are seen as two sides of the same coin. Thought processes are only a link, often not even the main one, in a chain of causes. For example, when a therapist is trying to determine the likelihood of recurrence of unipolar depression, he can make a more accurate prediction if he understands how critical the patient's spouse is, rather than relying on cognitive measures.
  6. Cognitive can be considered as a set of cognitive events, cognitive processes and cognitive structures. The term “cognitive events” refers to automatic thoughts, internal dialogue, and imagery. This does not mean that a person is constantly talking to himself. Rather, we can say that human behavior in most cases is thoughtless and automatic. A number of authors say that it is going “according to the script.” But there are times when automatism is interrupted, a person needs to make a decision under conditions of uncertainty, and then internal speech “turns on.” In cognitive behavioral theory, it is believed that its content can influence a person's feelings and behavior. But, as already mentioned, the way a person feels, behaves and interacts with others can also significantly influence his thoughts. A schema is a cognitive representation of past experience, unspoken rules that organize and direct information relating to the personality of the person himself. Schemas influence processes of evaluation of events and processes of adaptation. Because schemas are so important, the primary task of a cognitive behavioral therapist is to help patients understand how they interpret reality. In this regard, cognitive behavioral therapy works in a constructivist manner.
  7. Treatment actively involves the patient and family. The unit of analysis in cognitive behavioral psychotherapy is currently examples of family relationships and belief systems common to family members. Moreover, cognitive behavioral therapy has also become interested in how membership in certain social and cultural groups influences the patient's belief systems and behavior, includes the practice of alternative behavior in the psychotherapy session and in the real environment, provides a system of educational homework, an active reinforcement program, management notes and diaries, i.e. the psychotherapy technique is structured.
  8. The prognosis and effectiveness of treatment are determined in terms of the observed improvement in behavior. If previously behavioral psychotherapy had as its main goal the elimination or exclusion of unwanted behavior or response (aggression, tics, phobias), now the emphasis has shifted to teaching the patient positive behavior (self-confidence, positive thinking, achieving goals, etc.), activation of the resources of the individual and his environment. In other words, there is a shift from a pathogenetic to a sanogenetic approach.

Cognitive behavioral psychotherapy ( behavior modeling) is one of the leading areas of psychotherapy in the USA, Germany and a number of other countries, and is included in the standard of training for psychiatrists.

Behavior modeling- a method that is easily applicable in an outpatient setting, it is problem-oriented, it is more often called training, which attracts clients who would not like to be called “patients”. It stimulates independent decision problems, which is very important for patients with borderline disorders, which are often based on infantilism. In addition, many techniques of cognitive behavioral psychotherapy represent constructive coping strategies, helping patients acquire adaptation skills in the social environment.

Cognitive-behavioral psychotherapy refers to short-term methods of psychotherapy. It integrates cognitive, behavioral and emotional strategies for personality change; emphasizes the influence of cognitions and behavior on the emotional sphere and the functioning of the body in a broad social context. The term “cognitive” is used because disorders of emotions and behavior often depend on errors in the cognitive process and deficits in thinking. “Cognitions” include beliefs, attitudes, information about the individual and the environment, prediction and assessment of future events. Patients may misinterpret the stresses of life, judge themselves too harshly, come to the wrong conclusions, and have negative beliefs about themselves. A cognitive behavioral psychotherapist, working with a patient, applies and uses logical tricks and behavioral techniques for problem solving through the collaborative efforts of therapist and patient.

Cognitive behavioral psychotherapy has found wide application in the treatment of neurotic and psychosomatic disorders, addictive and aggressive behavior, anorexia nervosa.

Anxiety can be a normal and adaptive response to many situations. The ability to recognize and avoid threatening events is a necessary component of behavior. Some fears disappear without any intervention, but long-standing phobias can be assessed as a pathological response. Anxiety and depressive disorders are often associated with a pseudo-perception of the surrounding world and environmental demands, as well as rigid attitudes towards oneself. Depressed patients rate themselves as less capable than healthy individuals due to cognitive errors such as selective sampling, overgeneralization, all-or-nothing thinking, and minimizing positive events.

Behavioral psychotherapy serves as the means of choice for obsessive-phobic disorders and, if necessary, is supplemented by pharmacotherapy with tranquilizers, antidepressants, and beta blockers.

The following behavioral medicinal purposes carried out in patients with obsessive-phobic disorders: complete elimination or reduction of obsessive symptoms (thoughts, fears, actions); translating it into socially acceptable forms; elimination of individual factors (feeling of low value, lack of confidence), as well as violations of contacts horizontally or vertically, the need for control from a significant microsocial environment; elimination of secondary manifestations of the disease, such as social isolation, school maladjustment.

Cognitive behavioral psychotherapy for anorexia nervosa pursues the following short- and long-term therapeutic goals. Short term goals: restoration of premorbid body weight as necessary condition for psychotherapeutic work, as well as restoration of normal eating behavior. Long term goals: creating positive attitudes or developing alternative interests (other than dieting), updating a behavioral repertoire that gradually replaces anorexic behavior; treatment of phobia or fear of loss of weight control, body diagram disorders, which consists of the ability and need to recognize one’s own body; eliminating uncertainty and helplessness in contacts, regarding gender-role identity, as well as problems of separation from the parental home and accepting the role of an adult. These are the key goals of psychotherapy, which lead not only to changes in weight (symptom-centered level), but also to the resolution of psychological problems (person-centered level). The following algorithm of psychotherapeutic measures is common: cognitive-oriented behavioral psychotherapy, initially in an individual form. It consists of self-control techniques, goal scaling, assertive behavior training, problem solving training, signing contracts for weight restoration, and Jacobson's progressive muscle relaxation. The patient is then included in group psychotherapy. Intensive supportive psychotherapy is practiced. In parallel with this, systemic family psychotherapy is carried out.

Addictive behavior can be assessed in terms of positive (positive reinforcement) and negative consequences (negative reinforcement). When conducting psychotherapy, the distribution of both types of reinforcements is determined when assessing the patient's mental status. Positive reinforcement includes the pleasure of taking a psychoactive substance, the pleasant impressions associated with it, the absence of unpleasant withdrawal symptoms during the initial period of taking substances, maintaining social contacts with peers through drugs, and sometimes the conditional pleasantness of the patient’s role. Negative consequences addictive behavior - more common reason contacting a specialist. This is the appearance of physical complaints, deterioration of cognitive functions. To include such a patient in a treatment program, it is necessary to find “replacement behavior” without taking psychoactive substances or other types of deviant behavior. The scope of psychotherapeutic interventions depends on the development of social skills, the severity of cognitive distortions and cognitive deficits.

The goals of cognitive behavioral psychotherapy are presented as follows::

  1. conducting functional behavioral analysis;
  2. change in self-image;
  3. correction of maladaptive forms of behavior and irrational attitudes;
  4. development of competence in social functioning.

Behavioral and problem analysis is considered the most important diagnostic procedure in behavioral psychotherapy. The information should reflect the following points: specific signs of the situation (facilitating, aggravating conditions for the target behavior); expectations, attitudes, rules; behavioral manifestations (motor, emotion, cognition, physiological variables, frequency, deficit, excess, control); temporary consequences (short-term, long-term) with different quality (positive, negative) and with different localization (internal, external). Observation of behavior in natural situations and experimental analogies (for example, role-playing game), as well as verbal messages about situations and their consequences.

Purpose of Behavioral Analysis- functional and structural-topographic description of behavior. Behavioral analysis helps plan therapy and its progress, and also takes into account the influence of the microsocial environment on behavior. When conducting problem and behavioral analysis, there are several schemes. The first and most worked out is as follows:
1) describe detailed and behavior-dependent situational signs. Street, house, school - these are too global descriptions. More subtle differentiation is required;
2) reflect behavioral and life-related expectations, attitudes, definitions, plans and norms; all cognitive aspects of behavior in the present, past and future. They are often hidden, so they are difficult to detect even for an experienced psychotherapist at the first session;
3) identify biological factors manifested through symptoms or deviant behavior;
4) observe motor (verbal and non-verbal), emotional, cognitive (thoughts, pictures, dreams) and physiological behavioral signs. Global designation (for example, fear, claustrophobia) is of little use for subsequent psychotherapy. Qualitative and quantitative description of features is necessary;
5) evaluate the quantitative and qualitative consequences of behavior.

Another option for functional behavioral analysis is the compilation of a multimodal profile (Lazarus A. A.) - a specifically organized version of system analysis, carried out in 7 directions - BASIC-ID (according to the first English letters: behavior, affect, sensation, imagination, cognition, interpersonal relation, drugs - behavior, affect, sensations, ideas, cognitions, interpersonal relationships, drugs and biological factors). In practice, this is necessary for planning psychotherapy options and for training novice psychotherapists in the methods of cognitive behavioral psychotherapy. The use of a multimodal profile allows you to better understand the patient’s problem, correlates with the multi-axis diagnosis of mental disorders, and makes it possible to simultaneously outline options for psychotherapeutic work (see Lazarus Multimodal Psychotherapy).

When working on a typical problem, it is necessary to ask the patient a series of questions to clarify the existing difficulties: is the patient assessing events correctly? Are the patient's expectations realistic? Is the patient's point of view based on false conclusions? Is the patient's behavior appropriate in this situation? Is there really a problem? Was the patient able to find all possible solutions? Thus, the questions allow the therapist to build a cognitive-behavioral concept of why the patient is experiencing difficulties in a particular area. During the interview, ultimately, the psychotherapist's task is to select one or two key thoughts, attitudes, and behaviors for psychotherapeutic intervention. The first sessions are usually aimed at joining the patient, identifying the problem, overcoming helplessness, choosing a priority direction, discovering the connection between an irrational belief and an emotion, clarifying errors in thinking, identifying areas of possible change, and including the patient in a cognitive-behavioral approach.

The task of a cognitive-behavioral psychotherapist- make the patient an active participant in the process at all stages. One of the fundamental goals of cognitive behavioral psychotherapy is to establish a partnership between the patient and the therapist. This collaboration takes the form of a therapeutic contract in which the therapist and patient agree to work together to eliminate the latter's symptoms or behavior. Such joint activities pursue at least 3 goals:

  1. it reflects confidence that both have achievable goals at each stage of treatment;
  2. mutual understanding reduces the patient’s resistance, which often arises as a result of the psychotherapist being perceived as an aggressor or identifying him with a parent if he is trying to control the patient;
  3. a contract helps prevent misunderstandings between two partners. Failure to take into account the motives of the patient's behavior can force the psychotherapist to move blindly or lead the former to false conclusions about the tactics of psychotherapy and its failure.

Since CBT is a short-term treatment, this limited time must be used carefully. The central problem " psychotherapeutic training"- determination of the patient's motivation. To enhance motivation for treatment, the following principles are taken into account: joint determination of the goals and objectives of psychotherapy. It is important to work only on those decisions and commitments that are verbalized through “I want” and not “I would like”; drawing up a positive action plan, its achievability for each patient, careful planning of stages; the psychotherapist showing interest in the patient’s personality and his problem, reinforcing and supporting the slightest success; Strengthening motivation and responsibility for one’s results is facilitated by the “agenda” of each lesson, analysis of achievements and failures at each stage of psychotherapy. When signing a psychotherapeutic contract, it is recommended to write down the plan or repeat it using positive reinforcement techniques, communicating that this is a good plan that will contribute to the fulfillment of desires and recovery.

At the beginning of each interview session, a joint decision is made on which list of issues will be addressed. The formation of responsibility for one’s results is facilitated by an “agenda”, thanks to which it is possible to consistently work through psychotherapeutic “ targets" The “agenda” usually begins with a short review of the patient's experience from the last session. It includes feedback psychotherapist about homework. The patient is then encouraged to express what problems he would like to work on in class. Sometimes the psychotherapist himself suggests topics that he considers appropriate to include on the “agenda”. At the end of the session, the most important conclusions of the psychotherapeutic session are summarized (sometimes in writing), and the patient’s emotional state is analyzed. Together with him, the nature of independent homework, the task of which is to consolidate the knowledge or skills acquired in the lesson.

Behavioral techniques are focused on specific situations and actions. In contrast to strict cognitive techniques, behavioral procedures focus on how to act or cope with a situation rather than how to perceive it. Cognitive-behavioral techniques are based on changing inadequate thinking patterns, ideas with which a person reacts to external events, often accompanied by anxiety, aggression or depression. One of the fundamental goals of every behavioral technique is to change dysfunctional thinking. For example, if at the beginning of therapy the patient reports that nothing makes him happy, and after behavioral exercises he changes this attitude to a positive one, then the task is completed. Behavioral changes often occur as a result of cognitive changes.

The most well-known are the following behavioral and cognitive techniques: reciprocal inhibition; flood technique; implosion; paradoxical intention; induced anger technique; stop tap method; using imagination, hidden modeling, self-instruction training, relaxation methods at the same time; training of confident behavior; self-control methods; introspection; scaling technique; study of threatening consequences (decatastrophization); Advantages and disadvantages; interviewing witnesses; exploration of choice (alternatives) of thoughts and actions; paradoxical techniques, etc.

Modern cognitive-behavioral psychotherapy, emphasizing the importance of the principles of classical and operant learning, is not limited to them. IN last years it also absorbs the principles of the theory of information processing, communication and even large systems, as a result of which the methods and techniques of this direction in psychotherapy are modified and integrated.