Journal of Psychology & Psychotherapy
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Cognitive Behavioral Therapy: General Aspects and its Particular Technique

Minotta-Valencia Lina and Carlos Minotta Valencia^{* *}Correspondence: Carlos Minotta Valencia, Department of Psychotherapy, University of Antioquia Medellín-Colombia, Antioquia, Colombia, Email:

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Introduction

Cognitive therapy

In general terms, cognitive therapy is a treatment of a psychological nature that is developed between a professional specialist and a person who needs help due to disturbances of a relational, emotional, work, etc. order, it is carried out according to a theory systematized and based on certain philosophical principles and theoretical constructs, it aims to reduce suffering and behavioral disorders, derived from alterations in the logical structure of thought Psychotherapy has, in effect, the objective of partial reorganization, of the psychological apparatus and its functioning mechanism, that is, the cognitive processing of information, in the context of a significant symptomatic change [1-5].

Cognitive behavioral therapy comprises a philosophy of mind and theory of knowledge, which translates into a model of psychological intervention supported on a solid base of scientific research supported by empirical demonstration [6].

In the field of clinical and health psychology, cognitive behavioral therapy encompasses a wide variety of intervention techniques supported on the basis of theories such as information processing, behavioral sciences, social learning, etc.

Cognitive therapy is a dynamic, directive, orderly and relatively short-time procedure used to treat different psychiatric disorders [7]. Part of the assumption that people’s behaviors are determined by the way they perceive and interpret their world. Thus, it will be understood in part why; the experience that the subject has of the external world, will be configured by the content and mental structure that were formed in the person from their first experiences in childhood.

The subject’s behavior governed by rules and thought schemes that organize both his experience and his behavior are presupposed [8,9]. Schemas are patterns, guidelines and guidelines of thought that govern the way in which people process information from their environment and at the same time are the guide for behavior [10]. Bipolar dimensions are estimated in people according to two categories, which are their degree of activity, covering the continuum from the inactive-Valente extreme, to the activehypervalent positive extreme. The second dimension to be evaluated in a scheme is its degree of impermeability, which ranges from the non-modifiable to the susceptible to being transformed [8].

Regarding the content of the schemas, for example, in the case of depression, these give rise to three main patterns of cognition, called by Beck, Wright, Newman, and Bruce, the “cognitive triad”, namely.

The self-concept: consisting of the self-referential qualifications, manifested in the adjectives with which the person is designated when taken as an object of evaluation generally of a moral nature incidentally, it is the perception, about itself that the person builds perception that is manifested in positive (praise, selfacceptance, personal satisfaction) or negative (disqualification, criticism, disagreement with himself) appreciations.

The qualifying gaze of the experience of the self-relation with others and objects in the world: It manifests itself in recurring and persistent, warm or conflictive interpretations that color contact, or interpersonal relationships with others, configuring a constant pattern by way of performance; depending on the characteristics and attributions that the mind sets in relation to the qualities assumed in other people, in the experiences with them and the pleasant, pleasant or frustrating and painful conditions with material things or immaterial entities.

The last link in the triad corresponds to the vision projected forward in time, that is, its anticipatory or premonitory nature of the events to come, obscured by the fatality that feeds hopelessness and takes away the strength of the will or illuminated by alternatives in which the subject sees himself in the ability to choose.

What is common and characteristic of the three components of the cognitive triad, resides in the autonomy achieved by the structure of thought, to create a world made of representations, parallel to the real one, through processes of selective attention of sensory stimuli, of memory traces sensitive and experiential material extracted from the latter, to confirm, later, the solidity of its creation. In short, the notion of schema has a place, as representation has the performative potentiality of assuming the place of the “thing”, and the magical power of turning an interpretation into an absolute and unquestionable fact.

For Kendall the scheme emerges as an abstraction that emerges from the previous experience that guides the processes of attention and perception, the Scheme is a cognitive structure that filters, selects, categorizes, prioritizes processes and organizes the information and at the same time is made up of cognitive propositions, which refer to the content of the information. Schemas control cognitive operations, these, in turn, manipulate sensory information data. Automatic thinking would be a type of cognitive operation that is not deliberately presented in the subject [7]. Cognitive errors are also a form of expression of cognitive operations. And at the same time cognitive operations give rise to the so-called cognitive products as they are; images, behaviors, thoughts, attributions, self-affirmations. Cognitive products are the end result of information processing [4].

Some general principles that sustain cognitive therapy, according to Beck, Rush, Shaw, Emery are;

1) From the conjugation and interdependence of environmental stimuli (external) and internal stimuli, the patient’s cognitions emerge.

2) People’s cognitions, that is, her thoughts, reflects the configuration of the person’s vision of herself, others, her world, past and future.

3) Cognitions are closely related to emotions and behaviors.

4) Cognitive treatment techniques are aimed at the characterization and restructuring of distorted conceptions and dysfunctional schemes, which underlie the patient’s cognitions.

5) It is intended that the patient incorporated the method and cognitive ability to solve and overcome situations that he previously saw as insurmountable, through his own selfobservation and evaluation of his way of thinking.

6) Cognitive therapy promotes in the patient an adaptive, realistic and healthy way of approaching her problems [11].

The objective pursued with the vast diversity of cognitivebehavioral techniques and strategies is the testing of erroneous beliefs that predispose the patient to distort her experiences [9].

Cognitive therapy uses a wide variety of intervention methods and strategies in order to promote a reconfiguration of the person’s cognitive structure, so that they perceive, interpret, and judge the situations they face in the most rational way and adaptive possible. In short, it seeks to facilitate a change and flexibility in thought processes.

Cognitive therapy conceptualizes the problems of patients in cognitive terms, places special emphasis on the present of the patient; in particular it focuses on the dynamic formulation of the patient’s thoughts, behaviors and emotions.

Among the general objectives of a cognitive psychotherapy for the patient are the following;

Control negative automatic thoughts, identify the relationship between cognition, affect, and behavior, examine the evidence for and against distorted thoughts, replace these deviant interpretations with more realistic ones.

Learn to identify and modify the false beliefs that predispose him (patient), to distort her experiences.

Cognitive therapy treats its patients taking into account two levels of structure, a symptomatic level, which includes the complex of observable symptoms, recurrent behavior patterns, products, difficulties and problems that accompany the subject [11-23].

In addition to a “deep” level of structure whose mental contents can be inferred, these are schemes, central beliefs, ideas and conceptions that govern the way the patient interprets and lives their experiences, in other words, the symptomatic structure would be the problems. Client manifests, problems and symptoms that would be subordinate to the person’s cognitive structure.

Although Beck J. S. accepts that cognitive therapy must be adapted to the idiosyncrasy of each patient, he maintains that there are certain heuristic principles underlying any application of this treatment modality.

The patient’s problems are conceptualized in cognitive terms, first identifying the present thought and how it is accompanied by correlative feelings, which result in certain behavior. Then the triggering factors that contributed to the deployment of dysfunctional thoughts that did not allow the patient’s problems to be tackled in an adaptive way are discriminated. Then the predisposing factors or situations of the patient’s development that would be the hypothetical causes that would be at the origin of the present problems are tentatively formulated.

Requirement of the establishment of a solid therapeutic alliance, where the therapist shows the client empathy, authenticity and acceptance.

The development of cognitive therapy is carried out as teamwork, so it requires a mutual collaboration between the therapist and the patient. Communication is thus, then, dialogic and participatory on the part of both,

Cognitive therapy is oriented towards problem solving by setting explicit therapeutic goals and objectives that are measurable and quantifiable [24].

Cognitive therapy focuses on the here and now; it does not intervene on what happened in the past, current problems and disturbing situations that affect the patient here and now are addressed.

The therapist will tend to transmit the cognitive therapy method to the patient, so that he incorporates it and becomes his own therapist, once the patient has acquired knowledge about the way to proceed with cognitive therapy, he will be able to evaluate his own beliefs, thoughts, and how they affect your emotions and behaviors.

The relatively short duration of cognitive therapy is also one of its characteristics. This therapy modality has been designed to be carried out in a limited and relatively short time, the concept of the “deep” linked to the past of the person’s life history is reevaluated and importance is given to measuring the effectiveness of therapy through the evaluation of the results obtained.

The process of cognitive therapy is carried out according to a structure established for each session; this is developed according to a plan previously agreed between the therapist and the patient.

Through Socratic questioning and the guided discovery that the therapist applies to the patient’s beliefs, he learns to evaluate his own thoughts and behaviors, which allows the patient to make an empirical check of the usefulness, validity and functionality of his beliefs.

Cognitive therapy for its technical flexibility Beck J. S., Cognitive Therapy. Basic concepts and deepening. He uses various strategies in order to modify dysfunctional thought patterns. The cognitive therapist can use both cognitive techniques as well as techniques that belong to other psychotherapeutic currents, according to the objectives to be achieved for each particular case, and according to the needs of the patient.

Literature Review

Rational emotive behavioral ABC therapy

According to Ellis; People pursue goals or purposes (G) such as staying alive, enjoying life, establishing and maintaining intimate relationships, etc... When pursuing these purposes, they face adverse events or experiences, which he calls activating events (A), which lead people to experience consequences (C) that lead to feelings that can be considered healthy and even useful, such as frustration, among others. Although the consequences can also impact people in an unhealthy and harmful way, causing destructive emotions and feelings such as depression, serious anxiety [25,26].

Faced with adverse events, people find certain ways to deal with them, be it by accepting them, trying to modify them or reacting to them in a defeatist and non-functional way. The way people face such activating events (A), will be determined by their beliefs about such event (A), the beliefs that people adopt may well be rational (RB) or irrational (IB) and according to their degree of rationality or irrationality will experience feelings at the same time as functional and healthy behaviors or dysfunctional behaviors that will negatively affect their health (Ellis, A deeper and lasting brief therapy. Theoretical approach to rational emotional-behavioral therapy).

Irrational beliefs are usually of an absolutist, dogmatic and rigid nature that makes it difficult for the person to perform in their daily life, spoiling the person’s possibilities of coping. Beliefs can be images, ideas, or cognitions that are at an almost unconscious level. REBT rational emotional-behavioral therapy seeks to elicit new life philosophies (E) in its clients that lead to more functional and healthy adaptive actions.

Using a numerous and varied complex of rational and emotional techniques such as, for example; questioning or rational dispute, the confrontation of irrational beliefs, Socratic dialogue, and many other techniques, all of them used under logical assumptions, and also empirically proven their effectiveness. The REBT tries to test the veracity of the imperative, resistant, rigid, generalized and absolutist beliefs of its clients, working on their beliefs (B) so that these when interacting with (A), do not reproduce together with actions and feelings, negative consequences that, at the same time, lead clients to aggravated and disturbed emotional states, as well as the reaffirmation of a dysfunctional belief system, which perpetuates the feedback loop of new unpleasant consequences.

Multiaxial evaluation

The Multiaxial Assessment system allows the collection of information on different aspects and areas of the same patient. Information that once integrated allows not only a descriptive analysis of the mental health of the patient but also gives rise to the possibility of formulating hypotheses and inferences on the following points;

It makes it feasible to know the predictable course of the case, it allows evaluating the initial conditions of admission, the evolution of the case, it makes it possible to estimate the severity of the case, it makes it feasible to consider the prognosis that the treatment will have, it offers a greater probability of success in regarding the performance of differential diagnosis by having relevant and significant information to the case and the choice of the most appropriate intervention strategy.

The multiaxial evaluation proposed by the DSM IV, is composed of five axes or evaluation topics, namely;

1) Axis I. Clinical disorders or other problems that may be the object of clinical attention; generally they refer to the disorders for which the reason for consultation or is listed as the main diagnosis [27].

2) Axis II. Personality disorders, Mental retardation; this category of disorders can be useful to identify defense mechanisms, adaptive or maladaptive personality traits.

3) Axis III. Medical illnesses of the patient; according to DSM-IV. Within this category or axis, current medical illnesses that are relevant for understanding and addressing the reason for consultation are made explicit and detailed. The possibility that the mental disorder or disorders that the person harbors, may be related or associated with medical illnesses, is not ruled out. Carry out an exploratory study where the degree of incidence that biological processes and physical factors can have on the behavior and conduct of the person is analyzed and vice versa examine the incidence that psychological processes can have in the development of medical diseases in the patient offers greater thoroughness, accuracy and rigor in the diagnostic work of differential clarification [28].

4) Axis IV psychosocial and environmental problems.

5) Axis V. evaluation of global activity.

According to Pichot, López Ibor, Valdés Miyar, authored by DSM-IV; the multiaxial evaluation system allows a comprehensive evaluation, as complete as possible and in an orderly manner, of the psychosocial, environmental and activity level areas of the person that could go unnoticed if the therapist only takes into account the reason for consultation during the procedure in course of the interview.

The process of psychological evaluation of the patient includes a descriptive and functional analysis as well as a formulation of the case and its diagnosis [29]. In the descriptive analysis process; a list of the problems of the patient and her environment is made, including a description of the patient’s difficulties and the possible factors that are contributing to her difficulties. Issues are listed, and then described in detail.

General scheme of the cognitive restructuring application

Cognitive restructuring therapy assumes that; it is not external events or situations that cause or trigger our behaviors and emotions, they are in effect, the thoughts that we have about those events, those who are truly responsible for our actions and emotions. Consequently, in order to modify emotions, we will have to change the thoughts at their base.

Three of the main objectives pursued by the cognitive restructuring technique are:

Expose and show the person the domain that his thoughts have on his behavior and emotions.

1) Identify dysfunctional beliefs, maladaptive thoughts, and empirically invalid that the person expresses.

2) Modify the processes of cognition, beliefs, irrational thoughts for more useful, functional and practical.

The effect of thought on emotions is explained to the patient; for this, the basic theoretical postulates from which the cognitive model starts are outlined. As an example, a hypothetical conflictive situation and the thought of a person in front of it can be described to the patient, and then the patient is asked to indicate the possible feeling and behavior of the person in the face of the difficult situation.

Then the therapist generates new and alternate interpretations of the situation by putting himself in the shoes of the hypothetical subject, and then the patient is confronted about how the hypothetical subject would feel and act, if he thought about his situation in the alternative way proposed by the therapist. This procedure allows the patient to see the difference and contrast in behaviors and emotions generated from different thoughts about the same situation. The objective of this first stage of cognitive structuring is for the patient to be able to see the effects produced by the variation of a person’s thought on the same invariable situation on the person’s emotions and behavior. Examples of how different people react to the same situation can also be presented.

After this first phase of the cognitive restructuring technique, impractical and not useful thoughts are identified in the patient. In order to contrast them, and refute them with reality, applying didactic and persuasive strategies, such as debate, discussion in an atmosphere of pleasant dialogue that tests the validity and reveals the falsehood of the patient’s beliefs. Questions like the following serve this purpose; do you have evidence and proof about what you say? Are you completely certain? What consequences do you think that thought can lead to? Etc.

The therapist can also devise simple experiments or exercises called “reality tests” to be carried out by the patient in real life, in which they seek to test the veracity of the patient’s thoughts.

In an advanced phase of the cognitive restructuring process, the patient will be given instructions, so that it is he himself who refutes his harmful thoughts following the pattern of debate learned in the sections with the therapist. In order for the patient to carry out this undertaking, tasks are assigned to him around the house, such as the “three column method”; the patient divides a sheet into three columns in the first column he writes a situation, in the second column the harmful thought associated with it, and in a third column he writes alternative thoughts to the negative ones. The patient can also make use of role reversal by adopting the role of the therapist, or debate with others to refute their own thoughts.

Problem solving technique

According to D’Zurilla and Goldfried, the problem-solving technique does not conceive of the problems that people face from a pathological point of view, but rather as life situations that require a solution for the subject to achieve effective functioning.

Problem solving as a therapeutic intervention strategy aims to provide clients with a method designed to find solutions to circumstances, problems, practical issues, situations that people do not know how to deal with. People are trained to generate alternative perspectives on their problems and at the same time effective ways to address them. More than solving problems for clients, the therapist teaches a general and heuristic procedure so that they acquire the ability to solve problems and make decisions [30].

Indeed, the problem-solving technique comprises clearly participatory procedure delineation, ergo; it envisions the disposition of each of the phases or moments of therapy, to the submission of a consensus and agreement between the partners (clinician-client). This means that the treatment plan is not predetermined in advance, nor is it developed by the psychotherapist unilaterally and at the expense of the patient, who participates in all stages of therapy.

General scheme for troubleshooting

A general problem-solving scheme composed of eight stages will be presented below, formulated by Mckay, Davis and Fanning referred to in.

1) Detail in concrete terms the problem; namely to specify the situation that produces discomfort.

2) Profiling the problem, this is describing in detail the problematic situation in descriptive terms, about those who are part of the problem, and to what extent they are involved, when the problem appears, the way it appears, also its duration, the basic information to be investigated is; what is bothering? Who is involved? What happens? Where does it happen? When does it happen? And how does it happen? As for the answer that the subject emits, he asks what the person does. The questions to ask you are; what does the person do? Where does he do it? When does he do it? How does he do it? How does he feel? What motivates him to act like this? What does he intend to achieve with his performance?

3) Reclassify the problem; at this stage, different combinations are made between the elements of the situation and the response, which offers new perspectives on the situation.

4) Seek alternative goals in terms of solving the problem in light of new perspectives on the situation; that are achievable and that their achievement leads to the resolution of the problem.

5) Search and select strategies that allow achieving these objectives, you can use brainstorming, a technique designed to express a variety of ideas in relation to the problem posed, without applying any value judgment and avoiding the extravagant, absurd, laughable, fantastic or unrealizable that may seem, with the purpose of conceiving a high number of action alternatives and then doing the purification, selection and improvement of some of them having as a criterion degree of viability.

6) Describe and assess the positive and negative consequences that could arise from the implementation of the selected strategies. This implies weighing both the positive and negative consequences of each of the strategies separately according to the duration and quality of the impact of their application, taking into account not only the impact on a personal level but also on a social level.

7) Choose the alternative of action whose valuation indicates a higher probability of benefit and lower cost of response. Then describe the steps to carry it out, through an action guide according to a specific and structured plan.

8) Evaluate the results, taking into account, among other factors, the degree of satisfaction. And review of the entire process carried out, that is, look back.

The problem-solving technique can be summarized in the consequent abbreviated formula in the following steps, namely, first: recognition of a discomfort or dissatisfaction in relation to the current state of a situation, second: Identification of problem areas, or conflictive, third: demarcation and delimitation of a specific problem to be solved through action, fourth: formulation of several explanatory hypotheses that give clarity about the causal, triggering, sustaining, or perpetuating factors of the problem, fifth: selection of the most plausible hypothesis according to the following aspects, its heuristic power, predictive capacity and its degree of practical applicability, sixth: execution of a structured and systematic line of action, as it is consistent and harmonious, with the selected hypothesis, seventh: evaluation of the consequences and the impact of the action plan carried out.

Specifically, the activities that are carried out when a clinician attends to a client are, specifically, a collection of information, consensus, therapeutic framing, and design of a structured intervention protocol, followed by the intervention: application of techniques and finally the follow-up of the patient. Patient, this cycle of steps being able to be repeated, according to the demands of the same therapy, as long as the case may arise of new relevant information, not considered before and that merits its consideration, in the course of the intervention, or in any other phase [31,32].

The intrinsically collaborative design of the problem-solving technique, within the broad framework of a cognitive behavioral therapy, is part of a strategy that aims to return individual responsibility and involve the client in the knowledge and solution of their problems, not only It seeks to identify, and describe the problems, but also to generate together with him/her, the necessary knowledge to define appropriate actions that are in the process of change and the transformation of vital situations that affect their quality of life.

Of some strategies and techniques of therapy

Rational dispute: this technique openly and directly questions the patient’s beliefs, through questions that are aimed at confronting the evidence available to the patient to support their ideas, the rational dispute is used in order to demonstrate irrationality to the client and falsehood of their ideas. Cost benefit analysis: in this technique the client divides a sheet of paper in two, and writes on one side the advantages and the other the disadvantages that his way of thinking leads to, and or the functionality of his behavior or belief. At the end he will make the comparison between the two columns and see for himself the rationality, irrationality and usefulness of his belief or behavior. Hypothesis testing: The hypotheses that the client has about himself and his situation are empirically tested. The information that the client has about any event is used to then design an experiment that puts the client’s hypothesis into play, the experiment includes the retrieval of existing data on the patient’s history, through anamnesis and medical history.

Alternative modes of intervention are counseling, guidance and assistance: Conceive this as a space, where the role of the psychologist is to accompany the client in processes of personal clarification, and if necessary in moments of high anguish. The psychologist chooses to exercise a figure or role that would be primarily support and support, providing accompaniment and support to the client that allows him to envision possible solutions to the circumstances that affect him, and at the same time, make the most optimal decisions possible. The primary objective of this intervention modality is to offer the client a space of trust and security that allows them to express their feelings and thoughts without fear of being devalued, which in itself would produce a therapeutic effect even if it is only at a superficial level of containment.

General considerations on cognitive therapy and its social contribution

Cognitive therapy uses technical tools rigorously based on the results of scientific research, and in turn contextualized in order to solve the problems and needs of the client [33].

Through the data provided by the clinical studies, he performs a dialectical reformulation exercise between theory and practice, that is, he contrasts the degree to which the acquired theoretical background responds to the demands of professional practice, that is, in other words, verifies the state of relevance and updating of its theoretical postulates with the problems of the social and cultural reality and the client’s general context.

It confronts the degree of plausibility of the knowledge by subjecting to empirical verification the conceptual foundations under which the psychological exercise is sustained.

Conclusion

Identify and make critical analysis of the needs of the context in which professional psychological practice is exercised, in order to promote transformative actions.

As far as possible, designs health promotion and disease prevention projects in health care services, as well as prepares research projects aimed at diagnosing risk factors that affect mental and public health. It also studies various problems that a society may have, and then propose, according to the information obtained, lines of action that have a population impact.

Declaration of Interests

The authors declare that they have no financial interests or personal relationships that may have influenced the work reported in this document.

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