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Terapias Cognitivo-Comportamentales

What is Cognitive-Behavioral Therapy?

As the name implies, Cognitive-Behavioral Therapy is comprised of both cognitive and behavioral techniques. The premise underlying a cognitive-behavioral orientation is that difficulties in living, relationships, general health, etc., have their origin in (and are maintained by) both cognitive and behavioral factors.

The cognitive strategies of Cognitive-Behavioral Therapy aim to uncover the irrational and problematic thinking styles that often accompany psychological distress. These strategies believe that one's feelings are a direct extension of one's thoughts i.e, how you think determines how you feel. Thus, the aim of cognitive interventions is to challenge, and change, maladaptive, self-defeating cognitions.

The Behavioral techniques are also central to Cognitive-Behavioral Therapy. These techniques follow from the premise that maladaptive behaviors are learned, and therefore be unlearned as well. Among the behavioral techniques employed are training in both assertiveness and relaxation, and gradual desensitization to feared objects. Behavioral interventions have been demonstrated to be highly successful in the treatment of a broad range of specific problems including phobias, repetitive habits (nail-biting, hand- wringing, etc.), and bed-wetting, as well as more non-specific generalized complaints such as anxiety and/or depression.

Taken together, the cognitive and behavioral strategies create a balanced approach to understanding and treating common life-problems.

Consider the case of a child reared in a family in which any kind of conflict regularly resulted in physical punishmentadministered by a parent. On the basis of this formative experience, the individual in later life, perhaps in the context of a love relationship, may react with undue fear and distress in the face of minor conflicts. The reaction in this case may serve as an obstacle to the development of a healthy fulfilling relationship. By helping an individual to see this situation and develop more effective coping techniques and communications skills, the patient learns through experience that some conflict can be tolerated in the context of a relationship without extremely unpleasant consequences. It is a popular but false notion that cognitive-behavior therapists are unconcerned with an individual's life history. Historical events and relationships oftentimes represent essential information in understanding present functioning.

Cognitive therapy essentially involves helping an individual think in more effective ways.

As opposed to more psychodynamic or psychoanalytic theories in which feelings are viewed as primary and borne of formative experiences, cognitive therapy holds that our feelings can be modified by examining and changing our automatic thoughts processes.

Cognitive-behavioral therapy (CBT) has become the preferred treatment for most emotional and behavioral problems.


Conditions for which CBT should be the treatment of choice
>    Depression and mood swings
>    Shyness and social anxiety
>    Panic attacks and phobias
>    Obsessions and compulsions
>    Chronic anxiety or worry
>    Insomnia
>    Difficulty establishing or staying in relationships
>    Problems with marriage or other relationships you're already in
>    Job, career or school difficulties
>    Feeling "stressed out"
>    Insufficient self-esteem (accepting or respecting yourself)
>    Inadequate coping skills, or ill-chosen methods of coping
>    Shyness, passivity, procrastination and "passive aggression"
>    Substance abuse, co-dependency and "enabling"
>    Trouble keeping feelings such as anger, sadness, fear, guilt, shame,
       eagerness, excitement, etc., within bounds
>    Over-inhibition of feelings or expression

Just what is CBT? How does it work?

Behavior therapy helps you break the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.

Cognitive therapy teaches you how certain thinking patterns are causing your symptoms - by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.

When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.

 CBT is active therapy


In CBT, your therapist takes an active part in solving your problems. He or she doesn't settle for just nodding wisely while you carry the burden of finding the answers you came to therapy for.

You will receive a thorough diagnostic workup at the beginning of treatment - to make sure your needs and problems have been pinpointed as well as possible.

In many ways CBT resembles education, coaching or tutoring. Under expert guidance, as a CBT client you will share in setting treatment goals and in deciding which techniques work best for you personally.


Structured and focused

CBT provides clear structure and focus to treatment. Unlike therapies that easily drift off into interesting but unproductive side trips, CBT sticks to the point and changes course only when there are sound reasons for doing so.

As a CBT client, you will take on valuable "homework" assignments to speed your progress. These tasks - which are developed as much as possible with your own active participation - extend and multiply the results of the work done in your therapist's office.


What else is different about CBT?

Most people coming for therapy need to change something in their lives - whether it's the way they feel, the way they act, or how other people treat them. CBT focuses on finding out just what needs to be changed and what doesn't - and then works for those targeted changes.

Some exploration of people's life histories is necessary and desirable - if their current problems are closely tied to "unfinished emotional business" from the past.

Past vs. present and future

Focusing on the past (and on dreams) can at times help explain a person's difficulties. But these activities all too often do little to actually overcome them. Instead, in CBT we aim at rapid improvement in your feelings and moods, and early changes in any self-defeating behavior you may be caught up in. As you can see, CBT is more present-centered and forward-looking than traditional therapies.


CBT: The most clinically-proven therapy

CBT has been very thoroughly researched. In study after study, it has been shown to be as effective as drugs n treating both depression and anxiety.

In particular, CBT has been shown to be better than drugs in avoiding treatment failures and in preventing relapse after the end of treatment. If you are concerned about your ability to complete treatment and maintain your gains thereafter, keep this in mind.

No other type of psychotherapy has this  kind of clinically-proven track record.

 What about drug treatment?

CBT is usually employed by itself, without psychiatric drugs. For some people, however, drug treatment is needed to obtain a partial reduction in symptoms before CBT can be fully effective. Usually, though not always, it is preferable to try CBT alone before prescribing medications. This is for several reasons:

In addition, research studies have revealed these other facts about drug treatment for depression:

>  CBT and well-chosen drugs, when each is used alone, are about equally effective during the period of active treatment.
>  Adding drug treatment to CBT is not likely to get better results than using CBT alone (except in special cases such as the one described above).
>  Treatment failure is more likely when drugs are used, typically because of side effects.
>  Relapse after the end of treatment is more likely when only drugs have been used. This is believed to be because drugs, unlike CBT, do not encourage the development of valuable coping and emotional management skills.

Although the research data comparing CBT with drugs in the treatment of anxiety are somewhat less complete than they are in the case of depression, the indications so far are that a similar pattern exists.


CBT is usually brief

Most CBT patients are able to complete their treatment in just a few weeks or months - even for problems that traditional therapies often take years to resolve, or aren't able to resolve at all.

Meanwhile, for people with complex problems, or who are forced to live in adverse conditions beyond their control, longer-term treatment is also available.

How often will I be seen?

The answer to this question depends on your individual needs, your insurance plan, and the way your own therapist prefers to work.

As a rule, however, most people can expect to begin their treatment with weekly visits.

A few - particularly if they are in crisis - may begin with two or more sessions a week until their condition is stabilized enough that they can safely come only once a week.

What happens further on in treatment?

Again, the answer depends on how you are progressing, and on your therapist's and your own preferences. These are among the options that are often recommended . . .

>  Individual sessions every other week or monthly, combined with weekly group therapy meetings.

>  Individual sessions every other week or monthly, without participation in group therapy.

>  A planned break of several weeks, followed by resumption of weekly individual sessions for a period of time.

>  A trial termination of therapy - with the option of resuming if the need develops. Quite often, a follow-up session or phone contact is scheduled for a future date.


Cognitive Therapy

Part I

The working hypothesis of cognitive therapy is that the best way to solve emotional problems is to alter the patient's thinking. This form of psychotherapy concentrates mainly on the way people perceive the world and how they reason about it in everyday situations. Various techniques are used to expose and correct biased attention and recall, misinterpretation of events and statements, false assumptions, rigid beliefs, unjustified generalization, inferences based on insufficient evidence, magnifying and minimizing, thinking in extremes and absolutes, and other errors.

Treatment or Depression

Depression is still the chief indication for cognitive therapy. According to the theory, depressed people interpret their experience by schemes known as the depressive triad: I am worthless, the world is hostile, and the future is hopeless. They blame themselves for accidental misfortunes and explain events by general and pervasive circumstances rather than temporary and local ones. They believe the world makes unreasonable demands on them and expect to fail at whatever they undertake. The resulting loss of confidence and paralysis of will eventually lead to chronic fatigue and other physical symptoms as well.

Purpose of Therapy

The purpose of therapy is to make patients aware of their automatic thoughts, schemes, and reasoning errors, then develop new ways of thinking, test them, adjust them, and practice them. Weekly therapeutic sessions are usually held for 3 to 5 months, and sometimes followed by monthly sessions for as long as a year. Goals are defined and procedures are established at the start. A time limit is set to heighten the sense of urgency and the patient's concentration. In early sessions the patient's problems are defined and evaluated; in the middle sessions, attention passes to automatic thoughts and thinking errors; toward the end, patient and therapist work on schemes and cognitive sets.

Confronting Automatic Thoughts

The therapist brings automatic thoughts to light by discussing situations that provoke anger, fear, guilt, doubt, and sadness. Through questioning, patients are trained to identify these thoughts so that their insignificance or unreasonableness becomes obvious. Unlike obsessive ideas, automatic thoughts often seem reasonable even if the patient has consciously decided they are invalid. The patient is educated to ask repeatedly "What is the evidence? Are you oversimplifying or taking things out of context? Are there other explanations?" For example, a depressed person who believes that his supervisor at work considers him inadequate learns to tell himself that the supervisor thinks that way about everyone, and that no one else thinks he is inadequate.

The therapist challenges thoughts that kill initiative ("Why bother?"; "I don't have time"; "It's too hard"). Patients learn to think in degrees and probabilities rather than stark opposite alternatives -- not love or hate, failure or success, but degrees of liking and dislike, achievement and falling short.

Use of Imagery

Imagery is also used to correct thinking. Patients are asked to induce images to distance themselves and test the reality of their perceptions and fears. The imagery can be modified until the fantasy becomes more realistic and less depressing or frightening.

For Further Reading
Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery. Cognitive Therapy of Depression. New York, Guilford Press, 1979.

Aaron T. Beck, Gary Emery, and Ruth L. Greenberg. Anxiety Disorders and Phobias: A Cognitive Perspective. New York, Basic Books, 1985.

A. John Rush and Aaron T.Beck, eds. Cognitive Therapy. In Allen J. Frances and Robert E. Hales, eds. Review of Psychiatry, Vol. 7 Washington, D.C., American Psychiatric Press, 1988.

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