Behavioral Sciences Cognitive Behavioral Therapy

In family medicine and primary care, there are many patients with mental illness or symptoms of mental illness. Because family doctors have taken care of patients for a long time, they have a better understanding of their family and social background and are trusted by patients. For common mental illnesses, family doctors have the responsibility and ability to diagnose and provide appropriate treatment. In addition to simple consultation, health education, support and drug treatment, learning more about effective psychological treatment methods can provide patients with more benefits besides drug treatment. This article introduces one of the psychological treatments: cognitive behavioral therapy

Theoretical basis

The theoretical basis of cognitive behavioral therapy is that our thinking (cognition), feeling (emotion) and action (behavior) will affect each other (Figure 1). Mainly, our thoughts can affect our feelings and behaviors. Negative Thoughts give us negative or low emotions, which lead to negative and withdrawn behaviors. The results of these behaviors often reinforce our negative thoughts.

The goal of cognitive behavioral therapy is to enable patients to detect and realize that certain events in their lives can cause them to have negative thoughts, and to discover that such negative thoughts can trigger bad feelings and behaviors. During the treatment, the patient will be guided to try to face the same event with different thoughts or cognitions, or the patient will be asked to make certain behavioral changes so that the patient can experience different feelings and consequences, so that the patient will encounter the same event in the future. able to choose positive cognitions or behaviors.

​Historical evolution

Two thousand years ago, the ancient Roman philosopher Epictetus once said: “People are troubled not by the things themselves, but by their views on them.” After entering the twentieth century, behavioral therapy emerged due to the emergence of conditioning theory, and was mainly used to treat patients with fear or anxiety symptoms. By the late 20th century, some scholars discovered that cognitive errors were a major cause of unhealthy thoughts and behaviors. Among them, Albert Ellis, who proposed rational emotive behavior therapy, was the most important representative. He believes many people have some irrational assumptions about themselves and the world, such as: everyone must like me, otherwise I am a loser. We must do everything well, if things are not according to our expectations, going forward is a disaster. We cannot control whether we can be happy. We must find someone stronger than us to rely on. Everything in the world is fair. As long as we work hard enough, we can definitely change others. My thoughts, it must be right and there is a perfect answer and solution to every human problem.

Albert Ellis proposed the ABC model, which shows that the event that occurred is not the main cause of the consequences. The consequences are determined by whether we use the above-mentioned irrational assumptions to explain the event. To give an example: Tommy was depressed because he did not do well in the math test. What happened in this example was that Tommy did not do well in the math test. The consequence was that he suffered from depressive symptoms. The cause of Tommy depressive symptoms was his irrational belief. He believed he must do well in the exam, otherwise he will be a failure and worthless person. The therapist wants to change Tommy’s belief and let him know that failing the math test is unhappy, but it only means his current math study is not ideal, and it does not mean he is a useless loser.

Aaron Beck is also an important scholar in the field of cognitive therapy. He found that people with melancholic tendencies hold beliefs about themselves (I am worthless), the world (others ignore me) and the future (things will only get worse). Negative thoughts. At the same time, they often have some illogical thinking, that is, cognitive distortions or errors (Table 1). Sometimes these erroneous cognitions are suddenly triggered in life and appear automatically, without self-control. Aaron Beck calls this automation Thinking (automatic thoughts). For example: Tommy saw an oncoming friend pass by with a frown on his face without saying hello, so he decided that the friend must not like him. Cognitive therapy helps patients identify negative automatic thoughts, prove them to be unhelpful, and relearn helpful thoughts (perhaps a friend is unwell or worried about something, so does not see him to say hello, he should call his friend and should care about his friends) .

Modern cognitive behavioral therapy, in addition to cognitive therapy (cognitive change) and behavioral therapy (such as fear exposure and participation in pleasurable activities, etc.), often also teaches some relaxation techniques (such as muscle relaxation) and breathing training techniques, such as mindfulness-based cognitive therapy that emphasizes living in the present moment. Some treatments, such as acceptance and commitment therapy, can make patients more open and accepting of misconceptions, thereby reducing their impact on physical health.

Table of cognitive distortions

All or nothing thinkingExtreme thinking in black and white. If it’s not perfect, it’s a failure. Colleagues are either friends or enemies.
OvergeneralizationMake a conclusion after one life experience. A failed relationship makes you feel that you will never be able to have a good relationship with others in the future.
Jumping to conclusionsMaking subjective conclusions without enough evidence. When you see a stranger wandering around, you assume he must be a bad person.
Magnification or minimizationAmplifying negative life experiences or ignoring positive ones, a slight scratch on the car while parking makes you feel like you are the worst driver. Your boss praises you, but you think he is just too embarrassed to tell your shortcomings to your face.
Emotional reasoningTreat feelings as facts. You feel powerless over the problem, so the problem must be unsolvable
LabellingAn extreme form of oversimplification. A single act such as being drunk is labeled as an alcoholic.
PersonalizationWhen things go wrong, although you are not responsible, you will blame the results entirely on yourself. It can also be the opposite, and when things go wrong, you will blame someone else entirely.

Treatment process

Cognitive behavioral therapy is a structured, time-limited and goal-directed treatment. Generally speaking, it is once a week, 60 to 90 minutes each time, for 8 to 12 weeks, and the patient needs to actively participate. At the beginning, the therapist and the patient need to jointly set treatment goals. The patient may be troubled by a symptom or behavior. After evaluation, the therapist will work with the patient to find cognitive errors that may cause the patient’s problems and let the patient understand these. Cognitive errors are not based on facts, and then the patient’s cognitive beliefs are reorganized and continuously practiced and strengthened [5]. During therapy, the therapist may teach the patient some relaxation and problem-solving techniques. Before the end of each treatment session, the therapist and the patient jointly decide what homework they need to do when they go home, including detecting negative automatic thoughts in daily life and learning to replace them with positive thoughts. Other homework assignments include trying to do something you are afraid of doing, or participating in activities that make you happy, or doing breathing and muscle relaxation exercises. Due to resource constraints or patient cooperation reasons, some non-traditional one-to-one treatment methods, such as group therapy, self-help CBT, telephone or computer-assisted therapy, etc. have been described.

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