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Terapie Cognitiv Comportamentala Carte PDF
Terapie Cognitiv Comportamentala Carte PDF
Daniel DA VID
EDITORI ASOCIAI
Irina HOLDEVICI
tefan SZAMOSKOZI
Adriana BABAN
INTERVENIE
COGNITIV-COMPORTAMENTAL
N TULBURRI PSIHICE, PSIHOSOMATICE I
OPTIMIZARE UMAN
EDIIA II
COGNITIVE-BEHAVIOR THERAPY
IN
PSYCHOLOGICAL AND PSYCHOSOMATIC
DISORDERS AND HUMAN DEVELOPMENT
SECOND EDITION
BCU Cluj-Napoca
AUTORI:
Editor coordonator DanielDAVID, Asist. univ. dr., Univ.
Babe-Bolyai (UBB): Cap. I, 2, 3, 4, 5, 6, 7, 9, 10, 11,13, 14,
18, 19, 20.
Editori asociai Adriana BABAN, Conf. univ. dr., UBB:
Cap. 8. Irina HOLDEVICI, Prof. univ. dr., Univ. Bucureti, (UB):
Cap. 12. SZAMOSKOZI tefan, Conf. univ. dr., UBB: Cap. 15, 19.
Autori Anca DOMUA, Asist. univ. drd,
UBB: Cap. 16. JANOS Reka, Asist. univ. drd, UBB:
Cap. 17. Adrian OPRE, Asist. univ. drd, UBB: Cap.
7.
Cristina POJOGA, Medic - ClinicaMgdigfejjjljLSecia de gastroenterologie: Cap. 6.
Mihaela STNCULETE^aSSU^^^^^^i^aduHi,
Secia de psi^atoc. cap! 6.
\,
AUTHORS:
f* B&UOTEc*
Editor
^
FSJHOLOG'1. Daniel DAVID .
Ass^Bajb^to^^cisWr^r'Babe-Bolyai'' University (BBU):
Chap. 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 14, 18, 20.
Associate editors Adriana BABAN, Senior lecturer, Ph.D., BBU:
Chap. 8. Irina HOLDEVICI, Professor, Ph.D., Bucharest University (BU):
Chap. 12. SZAMOSKOZI tefan, Senior lecturer, Ph.D., UBB: Chap. 15, 19.
Contributors Anca DOMUA, Assistant professor, BBU: Chap. 16.
JANOS Reka, Assistant professor, BBU: Chap. 17. Adrian OPRE, Assistant
professor, BBU: Chap. 7. Cristina POJOGA, Physician, Fellow in gastroenterology, MD., Third Medical
Clinic, Department of Gastro-enterology, Cluj-Napoca: Chap. 6. Mihaela
STNCULETE, Physician, Fellow in psychiatry, MD., Adult Clinical
Hospital, Department of Psychiatry, Cluj-Napoca: Chap. 6.
Tehnoredactarea i coperta: Daniel PAUL; Corectura: autorii EDIIA
I -1998 EDIIA II - 2000
Editura: RISOPRINT, Copyright 1998, 2000 RISOPRINT ISBN:
973-9298-58-3, Cluj-Napoca, 2000
Volum sponsorizat de:
Fundaia Pentru o Societate Deschis din Romnia
The McDonell Program for the Advancement of Psychology in Romnia
II
Cuprins
INTRODUCERE la ediia a doua
IV
PREFA la ediia nti
VII
CUVNT CTRE CITITOR
IX
FOREWORD (lb. englez) ___________________________________________ XH_
PARTEA NTI Terapia cognitivcomportamental a anxietii i tulburrilor
psihosomatice________________________________
Cap.l. Psychotherapy as the cognitive psychologit views it (lb. englez)
3
Cap.2. Tehnici de intervenie la nivel cognitiv
23
Cap.3. Tehnici de intervenie la nivel comportamental
53
* Cap.4. Tehnici de intervenie la nivel biologic
63
Cap.5. Anxietatea din perspectiva tiinei cognitive
75
Cap.6. Intervenia cognitiv-comportamental n tulburrile de anxietate i
psihosomatice
81
Cap.7. Noi perspective n tratamentul anxietii; bombardamentul
subliminal
125
Cap.8. Anxiety prevention. A theoretical framework for mental health
promotion (lb. englez)
134
Cap.9. Concluzii i discuii ___________________________________________ 146
PARTEA A DOUA
Hipnoz, sugestie i hipnoterapie; modele teoretice i aplicaii practice
Cap.10. Hipnoterapia vzut de un psiholog cognitivist
151
Cap.11. Hypnosis and operaional readiness theory. An information
171
processing account (lb. englez)
Cap.12. Hipnoterapia
792
Cap.13. Hipnoterapia. Principii generale
216
Cap.14. Concluzii i discuii generale___________________________________ 221
PARTEA A TREIA
_____________ Diagnostic formativ i evaluare dinamic ______________________
Cap.15. Evaluare dinamic i modificabilitate cognitiv
225
Cap.16. nvarea mediat
238
Cap.l7. Inteligen i transfer
247
Cap. 18. Dynamic assessment of hypnotizability (lb. englez)
256
Cap. 19. Concluzii i discuii generale
265
Cap.20. Remarci generale
267
111
AUTORI:
Editor coordonator DanielDAVID, Asist. univ. dr., Univ.
Babe-Bolyai (UBB): Cap. 1, 2, 3, 4, 5, 6, 7, 9, 10, 11,13, 14,
18, 19, 20.
Editori asociai Adriana BABAN, Conf. univ. dr., UBB:
Cap. 8. Irina HOLDEVICJ, Prof. univ. dr., Univ. Bucureti, (UB):
Cap. 12. SZAMOSKOZl tefan, Conf. univ. dr., UBB: Cap. 15, 19.
Autori Anca DOMUA, Asist. univ. drd,
UBB: Cap. 16. JANOSReka, Asist. univ. drd, UBB:
Cap. 17. Adrian OPRE, Asist. univ. drd, UBB: Cap.
7.
Cristina POJOGA, Medic - CHnic^MgdjgeJ^gLSecia de gastroenterologie: Cap. 6.
Mihaela STNCULETEJ>^^^i^\oi^^s.&ia\%
Secia de psijmtetx Cap. 6.
AUTHORS:
U* B^^OTECA,
Editor
Daniel DAVID , Assi?ti^r^1f,^nr--ffrrP**"'"rilir-- TTn|-ii" University (BBU): Chap.
1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 14, 18, 20.
Associate editors Adriana BABAN, Senior lecturer, Ph.D., BBU:
Chap. 8. Irina HOLDEVICI, Professor, Ph.D., Bucharest University (BU):
Chap. 12. SZAMOSKOZl tefan, Senior lecturer, Ph.D., UBB: Chap. 15, 19.
Contributors Anca DOMUA, Assistant professor, BBU: Chap. 16.
JANOS Reka, Assistant professor, BBU: Chap. 17. Adrian OPRE, Assistant
professor, BBU: Chap. 7. Cristina POJOGA, Physician, Fellow in gastro-enterology,
MD., Third Medical
Clinic, Department of Gastro-enterology, Cluj-Napoca: Chap. 6. Mihaela
STNCULETE, Physician, Fellow in psychiatry, MD., Adult Clinical
Hospital, Department of Psychiatry, Cluj-Napoca: Chap. 6.
Tehnoredactarea i coperta: Daniel PAUL; Corectura: autorii EDIIA I
-1998 EDIIA II - 2000
Editura: RISOPRINT, Copyright 1998, 2000 RISOPRINT
ISBN: 973-9298-58-3, Cluj-Napoca, 2000
Volum sponsorizat de:
Fundaia Pentru o Societate Deschis din Romnia
The McDonell Program for the Advancement of Psychology in Romnia
II
Cuprins
INTRODUCERE la ediia a doua
IV
PREFA la ediia nti
VII
CUVNT CTRE CITITOR
IX
FOREWORD (lb. englez) ___________________________________________ XII_
PARTEA NTI Terapia cognitivcomportamental a anxietii i tulburrilor
psihosomatice ________________________________
Cap.l. Psychotherapy as the cognitive psychologist views it (lb. englez)
3
Cap.2. Tehnici de intervenie la nivel cognitiv
23
Cap.3. Tehnici de intervenie la nivel comportamental
53
Cap.4. Tehnici de intervenie la nivel biologic
63
Cap.5. Anxietatea din perspectiva tiinei cognitive
75
Cap.6. Intervenia cognitiv-comportamental n tulburrile de anxietate i
psihosomatice
81
Cap.7. Noi perspective n tratamentul anxietii; bombardamentul
subliminal
125
Cap.8. Anxiety prevention. A theoretical framework for mental health
promotion (lb. englez)
134
Cap.9. Concluzii i discuii ___________________________________________ 146
PARTEA A DOUA
Hipnoz, sugestie i hipnoterapie; modele teoretice i aplicaii practice ____________
Cap.10. Hipnoterapia vzut de un psiholog cognitivist
757
Cap.l 1. Hypnosis and operaional readiness theory. An information
777
processing account (lb. englez)
Cap.12. Hipnoterapia
792
Cap.13. Hipnoterapia. Principii generale
216
Cap.14. Concluzii i discuii generale ___________________________________ 227
PARTEA A TREIA
_____________ Diagnostic formativ i evaluare dinamic ______________________
Cap.15. Evaluare dinamic i modificabilitate cognitiv
225
Cap.16. nvarea mediat
238
Cap.17. Inteligen i transfer
247
Cap.18. Dynamic assessment of hypnotizability (lb. englez)
256"
Cap.19. Concluzii i discuii generale
265
Cap.20. Remarci generale
267
III
Content
IV
modificri: (1) temele sunt actualizate n acord cu evoluiile teoreticometodologice din domeniu; (2) omogenitatea lucrrii crete prin
preocuparea coordonatorului de a stimula interaciunile dintre autori precum
i de a impune o modalitate relativ constant de redactare a structurii
capitolelor; (3) s-au fcut unele corecturi de redactare care au scpat
corectorilor primei ediii din cauza presiunii redactrii lucrrii pn la
sfritul colii de var din 1997; (4) s-a mbuntit considerabil redactarea
n limba englez a capitolelor care abordeaz probleme importante n
practica i cercetarea psihoterapeutic n scopul creterii penetrantei i
receptrii lucrrii i la nivel internaional.
Scurt spus, acest volum este ediia a doua revizuit a primului
volum cu acelai titlu. Menionm ns c prin modificrile care s-au adus,
acest volum este o lucrare de sine stttoare cu un grad mare de omogenitate
care nu se mai reduce la o colecie de teme mai mult sau mai puin
prelucrate ca i n cazul primei ediii. El abordeaz ntr-o manier teoreticoaplicativ intervenia cognitiv-comportamental n tulburri psihice
(tulburrile de anxietate, sexuale i deficiena mental), tulburri
psihosomatice (acoperind aparatele respirator, cardiovascular, digestiv,
locomotor etc.) i optimizare uman (ex. tehnicile de relaxare n scopul
controlului stresului i emoiilor negative, antrenamentul asertiv etc).
Daniel DAVID
vi
VIII
Succesul de care s-a bucurat coala att prin numrul mare al participanilor
(60 studeni i 10 profesori) din 6 ri, (Romnia, SUA, Austria, Slovenia,
Estonia i Republica Moldova) ct i prin reflectarea activitilor desfurate
n mass-media au impulsionat apariia acestui volum. Dou precizri trebuie
fcute aici. Prima, i anume c la apariia acestui volum contribuie i autori
care nu au participat n mod direct la activitile colii de var (cei care apar
doar la lista autorilor si nu ca editori asociai ai lucrrii). Aceasta deoarece
aa cum am precizat mai sus, scopul acestui volum este nu doar de a
reproduce coninutul cursurilor colii de var ci i de a aprofunda unele
aspecte abordate acolo prin aportul unor oameni care formeaz noua
generaie n domeniu. A doua precizare se refer la faptul c dei temele
prezentate sunt reunite sub aceeai titulatur a terapiei cognitivcomportamentale, aceasta nu nseamn c punctele de vedere prezentate de
un autor n acest volum sunt automat mprtite i de ctre ceilali. Fiecare
autor i are autonomia i rspunderea sa pentru cele redactate, cum este i
normal ntr-o disciplin serioas, progresul fiind asigurat de un echilibru
raional ntre punctele de vedere concordante i divergente. Cu toate acestea,
ca i coordonator al lucrrii am ncercat s ofer un cadru omogen i un
echilibru de expresie ale punctelor de vedere pentru a asigura coerena
discursului i uurina receptrii lucrrii
Modul de organizare a lucrrii nu este unul ortodox, ieind din
normele paradigmatice clasice de redactare, dar este unul, considerm noi,
extrem de pragmatic n contextul tiinific actual. Ne referim aici la faptul c
unele capitole sunt redactate n limba englez, n timp ce altele sunt
redactate n limba romn. Cele redactate n limba romn au un scurt
rezumat n limba englez, iar cele redactate n limba englez au un rezumat
n limba romn. Redactarea n limba englez a unor capitole a fost dictat
de considerentul c problemele abordate aici sunt extrem de importante i
discutate i n literatura de specialitate, iar prezentarea lor n cadrul colii de
var s-a fcut n aceeai manier. Prin acest mod de abordare ncercm s
meninem de asemenea continuarea dialogului tiinific cu participanii din
strintate, dialog nceput cu ocazia cursurilor colii. n plus, lucrarea
conine termeni preluai direct din limba englez (dei acolo unde a fost
posibil autorii au efectuat traducerea i adaptarea lor). Aceasta din
urmtoarele considerente: (1) termenii sunt consacrai sub aceast form n
activitatea practicienilor din ar; (2) o adaptare a termenilor n limba
romn i-ar face s-i piard semnificaia original sau, ncercnd s o
pstrm, traducerea ar fi caraghioas i comic; (3) n plus n tiina
contemporan acceptarea unor termeni "pass partout" nu este un lucru
neobinuit (vezi "bit", "item" din limba englez n limba romn sau
"semem" din limba francez n limba englez etc). Rezumnd i
X
Daniel DA VID
XI
Foreword
Many people have passed through dramatic situations, sometimes
even terrible situations, but they survived because of the help of a relative,
friend, or priest. However, in the more severe cases they needed the help of
a professional psychotherapist or physician, to relieve their pain or to end
their suffering.
The term psychotherapy can be found in the scientific literature
with the following two meanings.
In soft terms, psychotherapy is a planned, intenional psychological
intervention, based on a rigorous theoretical and methodological system,
performed by one or more professionals - psychologists or physicians- for
the purpose of eliminating or relieving the symptoms of a patient (or more
patients - see group therapy) and/or for improving the performances of
healthy human subjects.
In strong terms, psychotherapy is understood as applied psychology
in clinical practice and/or for improving the performances of healthy human
subjects.
Hypnotherapy is the psychotherapy done by means of hypnotic
techniques.
In our century, any important application is preceded by a serious
fundamental research done in a scientific way. In psychotherapy, the
cognitive revolution that took place in the 60's, has imposed the cognitive
paradigm as one of the most privileged scientific paradigm in nowadays'
psychological research.
Gaining a core of rigorous theoretical and experimental results, the
cognitive psychology has penetrated almost all-important fields of
psychology, producing useful applications.
In consequence, cognitive-behavioral therapy is applied cognitive
psychology in clinical practice and/or for the improvement of the
performances of healthy human subjects. The structure of the book is
thought in the following way.
The first part approaches the cognitive-behavior therapy at three levels:
(1) the theoretical level: the fundamental assumptions and the
perspective of experimental cognitive-behavioral therapy;
(2) the methodological level: intervention techniques at cognitive,
behavioral and biological level;
XII
(3) the pragmatic level: the way these techniques work in clinical
practice and in improvement of the efficacy of normal subjects; here we
present case studies from literature and our own practice. This approach
will be detailed in regard to anxiety, sexual and psychosomatic
disorders.
Part two approaches cognitive-behavioral hypnotherapy at three levels:
(1) the theoretical level: the way the cognitive psychologist views
hypnosis and hypnotherapy,
(2) the methodological level: hypnotic intervention techniques at
cognitive, behavioral and biological level,
(3) the pragmatic level: the way these techniques work in clinical
practice and in improvement of the efficacy of normal subjects; here we
also present case studies from literature and our own practice.
Part three approaches dynamic assessment-formative diagnosis in
comparison to classic psychological testing in case of cognitive abilities and
hypnotizability.
XIII
PARTEA NTI
(PART ONE)
fi
Chapter 1
PSYCHOTHERAPY AS THE COGNITIVE
PSYCHOLOGIST VIEWSIT
- Dan DA VID Capitolul 1 este intitulat "Psihoterapia vzut de un psiholog
cognitivist". In acest capitol prezentm nucleul tare al perspectivei
cognitiv-comportamentale n psihoterapie, insistnd asupra
urmtoarelor aspecte: (1) analiza psihopatologiei subiectului uman
trebuie fcut simultan la patru nivele: cognitiv, comportamental,
biologic i subiectiv, elaborndu-se tehnici specifice de intervenie la
fiecare dintre acestea; (2) studiile de metaanaliz menioneaz terapia
cognitiv-comportamental ca fiind cea mai eficient form de
psihoterapie n tratamentul tulburrilor psihice i psihosomatice: (3)
psihoterapia cognitiv-comportamental experimental este o
perspectiv general asupra ntregii psihoterapii, formele clasice de
psihoterapie (dinamic-psihanalitice i umanist-experieniale) fiind
reinterpretate i asimilate treptat n termenii i cadrul terapiei
cognitiv-comportamentale.
Cuvinte cheie: angajament cognitiv-comportamental, analiz
multinivelar a psihopatologiei, modelul CBBS, program de cercetare.
Key-words: cognitive-behavioral approach, four-level analysis of the
psychopathology, CBBS model, research program.
r-'
period of the crisis occurs during the time when the old paradigm is
overthrown because of the failed predictions and of the gaps in its explanatory
completeness (Mc Connel, 1983). According to this view of the philosophy of
science, in psychotherapy we can talk about crisis in the 1960's when
behaviorism and behavioral therapy failed to explain how cognition and
information processing influence our behavior and emotions. (d). The
emergence of new scientific paradigms. When the old paradigm fails to
explain many phenomena that are relevant for science and fails important
predictions a new paradigm emerges. This is the moment when the scientific
revolution begins. In psychotherapy, at this point -the 1960's-cognitive
therapy emerged trying to explain how information processing influences our
behavior and emotions.
(e). The scientific revolution. This is characterized by (1) a spreading sense of
the inadequacy of existing institutions; (2) the textbooks which are rewritten
to teach the new paradigm; (3) the old ideas which are discarded as false. In
psychotherapy, the fight has taken place between behavioral therapy and
cognitive therapy.
(f). The return to normal science. When one side won, most of the evidence
accounted for by the other side is reinterpreted and integrated into its
theoretical system. In psychotherapy, cognitive therapy has won the fight with
behavioral therapy but, after that, it assimilated the right assumptions of
behavioral therapy. In this way cognitive-behavioral therapy has emerged.
Nowadays, there are three kinds of therapeutic approaches: (1) the dominant
one - cognitive-behavioral, (2) dynamic-psychoanalytic, (3) humanisticexperiential. However, as a dominant tendency, there is a strong attempt in
cognitive-behavioral therapy to assimilate the other two approaches by
accounting for their efficiency in its own terms.
not the cause of the symptomatology but a term that describes and names that
symptomatology. Anyway, tautological explanation can be useful in practice
as an interface theory. A patient may be satisfied with a tautological
explanation because it offers him a coherent perspective on his life and
symptoms and implies that there is a treatment for his problem.
* Experimental cognitive-behavioral therapy promotes a scientistpractitioner perspective in science
Psychotherapy practitioners are most of the time pragmatic and they
are interested in the theory and research that fits their current belief and the
observations of their own practice. This is a dangerous perspective because
often scientific knowledge does not fit common sense belief.
On the other hand, scientists and their research often lack
pragmatism, little knowledge of their research being effective and available
for use in clinical practice.
In response to this quite dangerous situation in psychotherapy,
experimental cognitive-behavioral therapy promotes the scientist-practitioner
perspective. This perspective tries to make practitioners more scientists and
scientists more practitioners. To make practitioners more scientists means that
practitioners are continuously employing, monitoring, evaluating, and testing
hypotheses at the moment-to-moment level with individual clients. Also
practitioners are stimulated, if not to do fundamental research, at least to be
interested in it keeping in touch with the newest discoveries in science. To
make scientists more practitioners means that scientists must be stimulated in
doing more ecological fundamental research that is closer to the practicai
needs and problems.
* Experimental cognitive-behavioral therapy makes a difference between the
efficiency of techniques and the scientific truth of the theory grounding those
techniques
The efficiency of a certain technique does not ensure the correctness
of the theory grounding it (see for example the relationship between
Mesmer's hypnotic techniques and his theory of animal magnetism).
Experimental cognitive-behavioral therapy agrees with and uses techniques
taken over from other therapies (e.g. dream analysis and interpretation from
dynamic-psychoanalytic therapy and empathic responses from humanisticexperiential therapy etc), but considers most of the underlying theories of
those techniques to be unscientific. Therefore, the experimental cognitivebehavioral therapy is an eclectic one at a technical level but not at a
theoretical level. It accounts forjJie_^fJiciejicxpXd3m^rn|i>psychoanalyticjind
humanistic-experiential techniques in terms ol_Jnfonriatidrrprocessing
paradigmTAsTstated before, it is very important for the evolutoirtrr science,
because only a scientific theory can strongly and significantly stimulate the
progress.
9
n0wadays
10
11
12
subjective level
events
8 ,.
|t
^
cognitive
level
--i.
5X 46
4"
: ---"*7
behavioral
level
environment
10f |9
biologica!
level
^____12
0f
the conflict (e.g. repressed motives, defense mechanisms and the cause of
repression as norms, values etc).
arrow 4-refers to the information processing of the internai stimuli. In the
case of panic attack for example, the body sensations generate and prime the
negative cognitive processing of those sensations. In turn, the negative
cognitive processing generates externai/internai cognitive discrepancy (e.g. I
am trembling but I do not want to tremble). Also, here we have to include the
direct impact of nervous system activity on the cognitive level. For example,
sometimes a high quantity of dopamine could generate hallucinations at
cognitive level.
arrow 5-refers to the fact that our behavior is an expression of information
processing (e.g. skill acquisition).
arrow 6-refers to information processing of internai stimuli during certain
behavior (e.g. skill acquisition). In some cases, the information processing of
internai stimuli could generate externai/internai cognitive discrepancy (e.g. I
am doing something against my beliefs).
arrow 7-refers to the fact that our behavior can influence the biological
level; (e.g. eating behavior, life style, etc).
arrow 8-refers to information processing of the subjective state, more
exactly the meaning of its labei. Information processing of the subjective state
could generate externai/internai cognitive discrepancy (e.g. I feel tense but I
want to be relaxed).
arrow 9-refers to the fact that our subjective state is a dependent variable,
or an effect of the interaction between the other three levels: cognitive,
behavioral, biological (see the classic experiment of Singer and Schachter,
1962).
arrow 10-refers to the fact that our negative or positive subjective state
determines coping mechanisms at three levels: cognitive, behavioral, and
biological. Coping mechanisms can be adaptive or maladaptive depending on
their consequences for the subject (cost and benefit) and the period of time he
resorts to them. Of course, coping mechanisms become the cause for another
subjective state which in turn will determine other coping mechanisms. In
others words, the same cognitive, behavioral and biological modifications
could be either causes or coping mechanisms depending on a subjective state,
w
hich they are connected to. The case conceptualization made by the
therapist will establish which subjective state is more important for the patient
a
nd in consequence, which cognitive, behavior and biological modifications
ar
e causes or coping mechanism of that subjective state.
arrow 11-refers to the modifications that our behavior induces into the
environment.
15
arrow 12-refers to the fact that the environment can influence our internai
milieu, not only by information processing, but also by direct action at the
biological level (e.g. action of viruses, bacteria, physic traumas).
Three pathways are very important for psychopathology (see fig. 1).
(a) 1.2.9. pathway - In this case the interaction among the environment,
internai stimuli and our information processing (externai/internai cognitive
discrepancy) or among our cognitive structures (internai cognitive
discrepancy) can determine a negative subjective state or a distress state. To
eliminate a distress state, we need modifications within:
our interactions with the environment -by problem solving techniques
and assertive training;
information processing -by cognitive restructuring techniques;
behavioral level -by behavioral modifications and hypnotherapeutic
techniques;
biological level -by chemotherapy, relaxation techniques, flooding,
desensitization and hypnotherapeutic techniques.
It is very important to make modifications at all levels (if possible),
otherwise our intervention will be efficient only for a short period of time
because the unmodified levels will remain as a prerequisite for other distress
states, in other situations.
1.2.9. pathway could be called or it is similar to primary appraisal
(see also Lazarus and Lazarus, 1994). In primary appraisal the interaction
between internai cognitive structure and both environment and internai
stimuli (externai/internai cognitive discrepancy) and also the interaction
among the internai cognitive structures (internai cognitive discrepancy)
generate a subjective state that could be positive, stressful or irrelevant neutral to well being. Primary appraisal includes information processing as
expectancies, attributions, labeling etc.
(b) 10.9. pathway - Human being is not passive to his subjective state
induced according to 1.2.9. pathway. In case of positive or negative
subjective states, the subject tries to cope with them. In this case, if coping
mechanisms are maladaptive, they can amplify our negative subjective state.
In fact, subject's symptomatology is a mixture of maladaptive cognition
and/or maladaptive coping mechanisms. As I mentioned above, the
conceptualization of clinical case made by therapist will establish which
modifications (cognitive, behavior and biological) are causes and which are
coping mechanisms regarding a specific subjective state. The stress
inoculation technique is useful at this point for teaching the patient adaptive
coping mechanisms to help him deal with distress. 10.9. pathway could be
called or it is similar to secondary appraisal (see also Lazarus and Lazarus,
1994). Secondary appraisal covers the ways the subjects cope with difficult
16
situations and it also monitors the results of the coping mechanisms, changing
both primary appraisal and coping mechanisms if necessary. Coping
mechanisms include problem-focused coping which tries to change the
cognitive discrepancy or, if that fails, emotional-focused coping which tries to
adjust one's subjective reaction to unchangeable cognitive discrepancy (see
stress inoculation training for adaptive emotional-focused coping).
(c) 8.9. pathway -In this case, the way the subject interprets and labels
his subjective state can influence his distress. For example, if he does not
understand his distress, and considers it a sign of an underlying undesirable
disorder, then this externai/internai cognitive discrepancy, in turn, will
amplify the distress state. A cognitive intervention is required at this point to
offer the patient a raional explanation for his distress. This explanation must
have the next characteristics:
to be accepted by the patient,
it has to explain to the patient the cause of his disorders and, meanwhile,
to suggest him that there is a treatment available,
it does not have to be true but it has to be useful.
As mentioned before, in experimental cognitive-behavioral therapy
three kinds of techniques are currently used: cognitive-behavioral, dynamicpsychoanalytic and humanistic-experiential techniques, all interpreted in
cognitive-behavioral theoretical perspectives. Below we present the way our
model interprets the efficiency of the dynamic-psychoanalytical or
humanistic-experiential therapies.
Dynamic-psychoanalytical therapies are sometime efficient because:
the therapeutic relationship reduces the intensity of the distress at the
beginning of the therapy and then generates the transference neurosis; these
are prerequisites to change maladaptive coping mechanisms;
the interpretation and the dream analysis could be useful in case of
internai discrepancy (unconscious conflict between undesired motives and
needs and our social norms and values). This is because they directly
influence 8.9 pathway and indirectly suggest to the patient the necessity for
change at 1.2.9 and 9.10 pathways (e.g. in the light of the interpretation
provided by the therapist, the subject understands that his cognitive style and
coping mechanisms were justified for a period of his life when he was a child,
but they are not justified in adulthood and they must and can be changed).
Anyway, these techniques have some disadvantages: they take a long
tune, they are useful only in individuals of the middle and upper social classes
w
'th a high level of education and they are useful mainly in individuals who
are not very seriously disturbed.
17
problems are most distressing for the patient and which are most quickly
amenable to therapeutic change.
As we mentioned before, a detailed and procedural description of
these phases can be found in any handbook of psychotherapy and clinical
psychology so that it isn't our intention to further detail this phase in this
chapter. However, we insist here that a correct conceptualization of any
clinical case must examine: (1) psychosocial or biological stressors; (2) how
the stressors are processed at cognitive level; (3) biological and behavior
modifications as a consequence of cognitive processing of stressors; (4)
subjective modification as a consequence of modifications of cognitive,
biological, behavior and cognitive levels. We remind here that cognitive and
behavior levels determine the quality of the subjective state and that the
biological level determines the intensity of the subjective state (also
remember that if the biological modification is very intense-very high
arousal- the subjective state will be a negative one no matter the cognitive and
behavior aspects); (5) coping mechanisms at cognitive, behavior and
biological levels.
Second phase (7-10 sessions -depending on the number of identified
problems). It supposes focusing on specific problems formulated in
behavioral terms by funcional analysis. Funcional analysis covers the next
steps (see chapter 3 for details): (1) identifying the antecedents and the
consequences of the behavior to be changed. The antecedents are represented
by stimuli (place, time, events), maladaptive cognition (e.g. unrealistic
expectancies etc), subjective state (e.g. negative etc), biological modification
(e.g. pain, arousal of the autonomous nervous system etc). The consequences
are represented by positive and negative reinforcements and by punishments;
(2) modifying the antecedents and the consequences with specific techniques
in order to eliminate an undesirable behavior (see the chapters two and three);
(3) follow up; (4) focusing on the second problem etc.
Third phase (5-7 sessions). It supposes focusing and changing by
means of specific techniques (e.g. changing maladaptive assumptions-chapter
2) general factors (such as cognitive style, general maladaptive cognitions,
health behavior, biological predisposition etc.) that predisposed, influenced,
started and maintained clinical disorders as a whole set of problems.
Fourth phase. It supposes the evaluation of the psychotherapy results
(e-g- with the single-case experiment methodology) and the follow-up process.
21
SELECTIVE REFERENCES/BIBLIOGRAFIE
SELECTIV
Beck, A. T. (1976J. Cognitive therapy and the emoional disorders, I.U.P.,
New-York. Bergin, A., & Garfield, L. (1994). Handbook of
psychotherapy and
behavioral change, J. W. & Sons, Inc., New York. David, D. (in press).
Cognitive-behavior therapy and hypnotherapy. Eysenck, M., & Keane, M. (1990).
Cognitive Psychology, LEA Publishers. Holdevici, I. (1996). Elemente de
psihoterapie, Editura AII, Bucureti. Ionescu, G. (1990). Psihoterapie, Editura
tiinific, Bucureti. Kuhn, Th. (1976). Structura revoluiilor tiinifice,
Bucureti, Editura
tiinific i Enciclopedic. Lazarus, R., & Lazarus, B. (1994). Passion and
reason. Making sense ofour
emotion, Oxford Press. McConnell, R. (1983). Parapsychology in the
context of science, Oxford
Press. Robin, R., Gosling, S., & Craik, K. (1999). An empiricul analysis
oftrends in
psychology, American Psychologist, 2, 117-128. Singer, J., & Schachter, S.
E. (1962). Cognitive, social and physiological
determinants of emotion state, Psychological Review, 63, 379 399. Stein, D.,
& Young, E. (1992). Cognitive science and clinical disorders,
Academic Press, U.K. Vianu, I. (1975/ Introducere n psihoterapie,
Edit. Dacia, Cluj Napoca.
Capitolul 2
TEHNICI DE INTERVENIE LA NIVEL
COGNITIV
- Dan DAVID Chapter 2 is entitled "Intervention techniques at cognitive level". In
this chapter, we present in details: cognitive restructuring techniques,
problem solving techniques and stress inoculation training. For each
technique we offer clinical examples from both our own clinical
practice and the clinical literature. Key-words: cognitive therapy.
Cuvinte cheie: terapie cognitiv.
INTRODUCERE
Odat generat prin mecanisme etiopatogenetice specifice (vezi fig.l, c),
simptomatologia tulburrilor psihice i psihosomatice este meninut i amplificat
prin intervenia unor factori generali nespecifici, extrem de compleci i greu de
controlat (vezi fig. 1, a i b).
Interpretarea simptomatologiei
de ctre pacient
Simptomatologie
>
tsy
Mecanisme
etiopatogenetice
specifice
Reaciile
mediului
social
LI
r^
23
Mecanisme
de coping
de coping
^*.
dezadaptativ
^V distres
Mecanisme
de coping
Distres
26
bujrea cauzelor
atn
hete lingvistice
<
pleci?
P: Cred c da.
(c). Tehnica jocului de rol
Aceast tehnic este indicat atunci cnd:
pacientul are probleme de interaciune social;
pacientul nu reuete s contientizeze coninutul informaion
dezadaptativ.
n acest caz, terapeutul joac rolul unei persoane cu care pacientu are
dificulti de relaionare, iar pacientul joac propriul rol. Aceast tehnic' l
va ajuta pe pacient s-i contientizeze coninuturile informaional
dezadaptative care i afecteaz performana n viaa cotidian. (d). Tehnica
observrii pacientului n cursul terapiei Orice schimbare a strii emoionale
este o ocazie de a chestio" pacientul cu privire la ce se gndete n momentul
respectiv.
(e). Tehnica nregistrrii zilnice a coninuturilor informaiona
dezadaptative
In acest caz, pacientul este rugat s completez formularul de mai j
n perioada dintre edinele terapeutice ori de cte ori experieniaz o situat
emoional negativ, avnd astfel o imagine comprehensiv i exhausti
asupra coninuturilor dezadaptative ale subiectului n condiii ecologice.
SITUAIA
Descrierea evenimentului extern care a
declanat distresul
Descrierea evenimentului intern (senzaii
fizice, gnduri, imagini) care a declanat
distresul
TRIREA EMOIONALA
Tipul de emoie (anxios, suprat etc.)
Intensitatea emoiei pe o scal 1-100
Descriere
In ce msur le considerai adevrate pe o
scal 0-100
CONINUTUL INFORMAIONAL
DEZADAPTATIV
Descriere
In ce msur le considerai adevrate pe o
scal 0-100
CONINUTUL INFORMAIONAL
ADAPTATIV CARE AR TREBUI S
NLOCUIASC CONINUTUL
INFORMAIONAL DEZADAPTATIV
REZULTATE
32
modificare
coninuturilor
informaionale
Raionalismul
Raionalismul i are originea n Grecia Antic (Pitagora, Aristotd
Platon) i n secolul XVII-XVIII (Descartes, Leibnitz, Spinoza). Nucleul tar
al acestei perspective filozofice este urmtorul:
sursa cunotinelor noastre este raionamentul deductiv i logi
pornind de la adevruri universale independente de experienj
apriori, neschimbabile, absolute;
realitatea este partea stabil care se ascunde dincolo de realitii
perceptuale imediate; ea poate fi cunoscut doar cu ajutorul acesto
adevruri universale;
cunotinele valide sunt doar acelea care sunt logic consistente 9
corespund unor standarde recunoscute de adevr, raiune.
n TCC raionalismul este reprezentat de tehnicile elaborate de A.
Ellis (1962). EUis consider coninuturile informaionale dezadaptativl
contiente sau contientizabile (specific irrational beliefs) i procesela
informaionale dezadaptative contiente sau contientizabile (irrational
beliefs) rspunztoare de problemele emoionale ale subiecilor.
Procesrile informaionale dezadaptative se mpart n trei categorii
caracterizate de mai multe stiluri cognitive.
Pattemul (1): Trebuie s dau tot ce pot n ceea ce fac i s ctig
simpatia tuturor, altfel sunt o persoan care nu merit nimic;
Pattemul (2): Ceilali trebuie s s m trateze cinstit i corect, altfel
trebuie pedepsii;
Pattemul (3): Condiiile mele de via trebuie s fie astfel organizate!
nct fr mare efort i frustrare s ating toate obiectivele importante ale
vieii.
Aceste procesri informaionale dezadaptative genereaz coninuturi
informaionale dezadaptative la interfaa cu evenimente specifice. Pentru,
modificarea coninuturilor informaionale dezadaptative, Ellis a elaborai
tehnici de terapie raional-emotiv.
Tehnicile de terapie raional-emotiv modific coninutul!
informaional dezadaptativ al pacientului ntr-o manier direct i asertiv,
cerndu-i acestuia s explice raiunea i logica acestora. Pentru a putea realiza
eficace o astfel de intervenie este foarte important ca terapeutul s cunoasc]
foarte bine logica, retorica i teoria argumentrii (ex. erorile de raionament
etc). Se insist asupra: argumentrii defectuoase n favoarea unor credine
iraionale pe care o face pacientul, explicaiei eronate pe care o angajeaz
pacientul fa de propriile simptome, ^ontFadiciUe din gndirea lui i
premisele iraionale i absolutiste pe care le utilizeaz n prelucrarea realitii
n care triete.
34
jrect;ve,
37
T: Ieri mi-ai spus c te-au certat i te-au pedepsit dup ce le-ai spus
c ai sosit acas dup ora 23, considernd c ai vagabondat prin ora, dei tu
ai fost la un cerc de poezie.
P: Da, aa este. Ei nu suport gndul c a putea da admitere la
filologic M-au pedepsit mai aspru dect meritam.
T: Cum se mpac asta cu armonia i buna nelegere?
P: (pauz). Nu tiu.
T: Sigur c este bine s fii cinstit n general fr a fetiiza ns acest
lucru. A fi cinstit n sens realist cred c nseamn a face mai mult bine dect
ru i nu a face ntotdeauna bine. Tu ce crezi?
P: Poate c ai dreptate. Puteam evita toat tevatura spunndu-le c
am venit acas la ora 22. n fond, nu am fcut nimic ru.
T: Cred c ar trebui s mai discutm despre relaia ntre a fi cinstit i
a fi ntotdeauna cinstit ntr-un cadru mai pragmatic, lund n considerare i
conceptul de responsabilitate i asumarea consecinelor comportamentelor
tale.
(J). Tehnica controlului contient
Pacientul poate fi contientizat de ctre terapeut asupra unor tendine
n prelucrarea realitii cu efecte negative asupra simptomatologiei, putndule astfel controla. n anxietate spre exemplu, pacienii au tendina de a
prelucra preferenial din mediu stimulii anxiogeni. Acest pattern cognitiv
duce la amplificarea simptomelor anxietii. n consecin, anxietatea astfel
stimulat va favoriza din nou acel pattern cognitiv, intrndu-se astfel ntr-un
cerc vicios ce amplific simptomatologia. Pacientul va fi nvat s caute
intenionat i contient n mediu stimuli neutri emoional sau cu valen
pozitiv, ca o contrapondere la tendina lui automat de a selecta n special
stimuli anxiogeni. Aceti stimuli urmeaz s fie prelucrai n continuare
preferenial.
(g). Tehnica costurilor i beneficiilor
Pacientului i se cere s fac o list cu costurile i beneficiile pe care
cogniiile dezadaptative i le aduc. Aici experiena i pregtire terapeutului
sunt decisive n a scoate n eviden dezavantajele pe care cogniiile
subiectului le presupun sub aspectul relaiilor cu ceilali, al tririlor
emoionale, autocontrolului comportamental etc.
Constructivismul
Constructivismul i are rdcinile n filozofia
kantian i
neokantian i mai recent n scrierile lui Poppers, Campbell,
Piaget, Kelly,
Goodman, Kuhn etc. Asumpiile sale fundamentale sunt:
sursa cunotinelor noastre este capacitatea
simbolic i
imaginativ a subiectului uman; cunotinele sunt
mai degrab
inventate dect descoperite. Nu conteaz att valoarea lor de adevr,
39
ct mai ales valoarea lor adaptativ pentru subiect, (it does not ha
to be true to be useful - vezi religia);
nu exist o singur realitate stabil, absolut, ci fiecare om
construiete propria sa realitate.
n terapia cognitiv-comportamental, constructivismul acreditea
ideea c tulburrile emoionale sunt expresia faptului c sistemul cunotine
al subiectului nu mai este adaptativ. n consecin, terapeu' trebuie s
faciliteze pacientului restructurarea sistemului de cunotine pr construcia
unuia nou, adaptativ n cadrul unei relaii terapeutice cald stabile,
securizante.
Tehnici de modificare constructiviste
Aceste tehnici au urmtoarele caracteristici:
sunt mai mult creative dect corective;
nu se atac direct coninutul informaional dezadaptativ, ci
pacientul este ajutat s neleag faptul c acesta era adaptativ pentni
o anumit etap a vieii sale, dar acum este necesar elaborarea unui1
coninut informaional nou, care s asigure adaptarea la noile condiiq
de via;
terapeutul asist pacientul n gsirea unei noi perspective asupra
realitii (trecute, prezente i viitoare), a unei noi identiti care chiarj
dac nu este valid, corect, este adaptativ pentru subiect n
condiiile sale de via. Aici pot fi enumerate tehnicile dinamice iumanile (separate ns
de angajamentul lor teoretic) ca: interpretarea, analiza viselor, asociaiile
libere, congruena, acceptarea necondiionat, empatia, experienierea unorj
noi triri emoionale etc.
Exemplificm aceste tehnici prin tehnica interpretrii viselor ^
tehnica jocului de rol n condiii ecologice.
(a). Tehnica interpretrii viselor
Tehnica se aplic n cazul n care un vis repetitiv anxietizeaz
pacientul sau n cazul n care se urmrete obinerea de informaii
suplimentare (dac pacientul declar c nu i vine nimic n minte prin asociaii
libere, de la temele discutate n terapie se trece la analiza viselor pe car
acesta le are) pentru a construi o interpretare dinamic.
Tehnica interpretrii viselor angajeaz urmtorul algoritm.
(1). Pacientul este pus s-i povesteasc visul. Terapeutul noteaz
temele visului, evenimentele n ordinea prezentat de pacient. De asemenea
este atent la emoiile expereniate de pacient n cursul povestirii i legtura lor
cu temele expuse, relaiile spaiale care pot semnifica relaii interpersonale.
40
41
ETAPA 3
(5) atacarea
ETAPA 4
Tehnici de identificare i modificare a proceselor informaii
contiente sau contientizabile
rin:
Procesele informaionale contiente sunt cele care gener^
con
coninuturi informaionale dezadaptative n situaii specifice. Ele au un de
c
generalitate mult mai mare dect coninuturile informaiol dezadaptative.
Identificarea proceselor informaionale contiente se fac ultimele etape ale
terapiei printr-un proces de generalizare inductiv pori de la coninuturile goritminformaionale dezadaptative identificate pn atunci cursul terapiei i
TEHNICA REZOLVRII DE PROBLEME I Jtfsituaiile n care aceste coninuturi informaionale apari formalizare cu
ANTRENAMENTULASERTIV
problematice
ajutorul regulii dac/atunci.
Sunt utilizate pentru a modifica , rezol
n cadrul
Dac subiectul le consider eronate, este foarte bine, aplicndu-sd Onoare div^ * ** &*,*** ^ pe
continuare tehnicile descrise n etapa 3. Dac le consider adevrate, atu
ecanismulu! 1.2.9. (vezi ^.J1^ soluiilor adecvate.
trebuie realizat modificarea lor. Modificarea acestor procese informaiol
dezadaptative contiente se face prin aceleai tehnici ca i n cal
coninuturilor informaionale dezadaptative (vezi etapa 2). Ori(
modificarea lor este uurat de faptul c, coninutul informaional care e|
expresia lor a fost deja modificat.
^^^^Sfc^o.--*:
ETAPA 5
Tehnici de identificare i modificare a coninuturilor
procesrilor informaionale dezadaptative incontiente
Neputnd fi contientizate i verbalizate, aceste coninuturi procesri
informaionale dezadaptative nu pot fi modificate n mod direct. Eli pot fi ns
modificate indirect prin modificarea direct a outputurilor
comportamentale i fiziologice. Astfel, tehnicile de intervenie la nrfl
comportamental (ex. tehnici operante) i tehnicile de intervenie la niva
biologic (flooding, relaxare) modific indirect coninutul prelucrrile^
informaionale dezadaptative (vezi capitolele 3 i 4).
Cercetrile recente n psihologia cognitiv sugereaz un posibt
algoritm pentru intervenia direct asupra coninuturilor i procesri^B
informaionale dezadaptative incontiente:
(1) analiza atent a inputului - a situaiilor externe i interne c
determin tulburarea emoional;
(2) analiza atent a outputului comportamental, fiziologic M
subiectiv al coninuturilor i procesrilor informaionale dezadaptatnj
incontiente;
(3) analiza detaliat a relaiei ntre (1) i (2), indicat chiar n situai
ecologice;
(4) inferena coninuturilor i procesrilor informaional
incontiente ce mediaz relaia ntre (1) i (2);
46
sensul c ea ghideaz g
Etapele tehnicii i
identificarea problemei - Uare esic tnv ----- _ t
pus i corect identificat este pe jumtate rezolvat n sensul c ea
sugereaz locul unde trebuie s cutm soluiile;
stabilirea scopurilor - Ce urmeaz s fac, cum doresc s stea
lucrurile?
generarea soluiilor alternative - Ce pot face pentru a-mi atinge
scopurile? n prima faz se genereaz necritic un numr ct mai mare
de soluii. Apoi se analizeaz soluiile propuse i se selecteaz cele
care sunt realiste i au valene ecologice;
"
. considerarea cornecin/elor- Ce s-ar -se costurile i
asta' Fiecare soluie este discutata stabilmou
urmtoarea ca
reia ntregul
ierarhie.
In
cazul
n
care
nici
o
soluie
nu
a
funcionat
se
reia
ntregul
p, f, terarnizate , funcie de ,oare *r f-^
f 70
" ' Ac oenerare a soluiilor i
joc de rol pentru a pregti subiectul in vederea imp
soluia, se trece
ii n care *w
i
proces
insistndu-se mai mult
evaluare V lUlivuv. ---------; la ncercarea altei soluii asupra fazei de generare
de pregtire a implementrii lor ecologice.
47
coninutul povestit (c) s fie verificabil (dar greu verificabil n cazul n care
este fals). Cum transmii un mesaj critic- Mesajul s fie impersonal,
Etapele antrenamentului asertiv sunt descrise n cele ce urmeaz
(1) Examineaz modul n care interacionezi cu ceilali. Ex constructiv, precedat de mesaje pozitive. Ex. Un pacient ntrzie nejustificat
situaii n care ar trebui s te compori mai asertiv? Ai uneori opinii la edina terapeutic. Mesaj critic corect: "E bine c i-ai realizat sarcinile
sentimente pe care le ascunzi deoarece i-e team de ceea ce s-ar ntrrJ date edina trecut dar faptul c ai ntrziat astzi m pune n ncurctur: s
dac le-ai exprima? i se ntmpl uneori s-i lai calmul la o parte i si ncepem edina cu ntrziere dereglnd tot programul meu sau s amnm
manifeti agresiv fa de ceilali? Ar fi util s pstrezi un jurnal n care ntlnirea. Atept ca data viitoare s soseti la timp, acum hai s ncepem".
notezi situaiile n care te-ai comportat timid, cele n care ai reacionat agre ^gca| critic incorect: "Ce s-a ntmplat? Te atept de o jumtate de or. Eti
i cele n care ai acionat asertiv.
neserios. Bun, hai s ncepem".
(2) Selecteaz situaiile n care ar fi mai util s te compori asertl
(5) Observ unul sau mai multe modele care se comport n mod
Poi include situaiile n care te-ai comportat excesiv de politicos, i-ai cerut asertiv. Studiaz modul lor de abordare verbal i non-verbal n situaiile n
mod exagerat scuze, ai fost timid sau ai permis s i se traseze sarcini prj care tu ai dificulti. Compar consecinele comportamentului lor cu cele ale
care s-a profitat de tine, trind n acelai timp sentimente de furie, jen, teai comportamentului tu. Dac este posibil, discut cu ei modul lor de
de ceilali sau autocritic pentru lipsa curajului de a-i exprima proprii! comportament i sentimentele pe care le au datorit acestuia.
opinii. De asemenea este necesar intervenia i n cazul situaiilor n care ti
(6) F o list cu mai multe variante de comportament asertiv
ai exprimat extrem de agresiv sau nu ai inut seama de drepturile celorlali.
folositoare n diverse situaii.
(3) Concentreaz-te pe un anumit incident din trecut. nchide ocl i
(7) nchide ochii i imagineaz-te pe tine nsui utiliznd fiecare
imagineaz-i ct mai viu detaliile, inclusiv ceea ce ai spus tu i ceai
dintre variantele de mai sus, gndindu-te i n ce situaii pot fi folosite,
persoan, precum i ceea ce ai simit n acel moment i dup aceea.
precum i ce consecine ar avea. Selecteaz o alternativ sau o combinaie de
(4) Examineaz i apoi noteaz pe o hrtie caracteristii
alternative care crezi c ar fi cea mai eficient pentru tine. Exerseaz aceast
urmtoarelor elemente ale comportamentului tu:
variant n imaginar pn cnd te simi sigur i eti convins c va funciona.
contactul vizual: te-ai uitat direct la acea persoan, ai inut priv
(8) Practic jocul de rol pentru alternativa aleas mpreun cu
n pmnt sau ai avut o privire fix, ostil?
altcineva: un prieten sau un consilier care s-i ofere i feed-back n legtur
gestica: trebuie s sublinieze n mod eficient mesajul. Ges
cu comportamentul tu. Modific secvenele pe care le consideri timide,
dezordonate sugereaz nervozitate, n timp ce alte gesturi pot sug(
agresive sau caraghioase pn te simi confortabil cu propriul comportament.
timiditate (unele micri stereotipe, ca de exemplu frecarea minilor);
Compar-1 cu caracteristicile generale ale unui comportament asertiv,
postura corpului: cea mai indicat este poziia frontal, pos
prezentate la punctul (4).
vertical a capului i o distan potrivit fa de interlocutor;
(9) Repet paii (7) i (8) pn i dezvoli o manier asertiv de
volumul i tonul vocii: pentru a sublinia importana mesajului, e:
interaciune cu ceilali, un mod de comportament despre care crezi c te va
necesar un volum normal pentru conversaie i un ton hotrt;
fluena vorbirii: mesajul s fie exprimat clar i rar;
ajuta cel mai bine.
timpul scurs ntre producerea incidentului analizat i apari,
(10) Utilizeaz alternativa aleas ntr-o situaie din viaa real. Este
reaciei tale: n general exprimrile spontane sunt cele mai indicate, anumite
normal s existe o anumit anxietate la prima ncercare de a fi asertiv. Dac
situaii trebuie rezolvate dup un timp mai lung (de exemp corectarea unei
nc i-e team s te compori asertiv, repet paii (5)-(8). Pentru acele
declaraii eronate a efului este mai bine s se fac ntre pal ochi, dect n faa
Persoane (puine la numr) care nu reuesc s-i dezvolte sigurana necesar
grupului cruia el i face respectiva declaraie);
Pentru a ncerca s devin asertive, este indicat consilierea de ctre un
coninutul mesajului: dac acesta a fost asertiv, agresiv sau no
| Prfesionist.
asertiv;
(11) Reflect la rezultatele efortului tu. Gndete-te la
credibilitatea mesajului. Pentru a fi credibil, un mesaj (adevr: sau
racteristicile verbale i non-verbale ale comportamentului asertiv prezentate
fals) trebuie s conin: (a) ct mai multe detalii fizice (b) ct mai muli
Punctul (4). Care componente ale rspunsului tu au fost asertive, agresive
implicare emoional care se refer att la coninutul evenimentelor povestit!
,u non-asertive? Care au fost consecinele comportamentului tu? Cum te-ai
ct i la emoiile resimite de povestitor n cursul povestiri legate a
it dup ce ai ncercat acest nou tip de interaciune?
48
49
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Andrews, G., & Harvey, P. (1981). Does psychotherapy benefit neur,
patients? A reanalysis ofthe Smith, Glass, and Miller data, Archi /
ofGeneral Psychiatry, 36, 1203-1208. Befcfc, A-^T. (T976). Cognitive
therapy and the emotionaal disorders, I.U
Ne\-YorE>^ , Da vid, D. (1996). Memoria implicit;
clarificri teoretico-metodologicel
implicaii practice,%udia nr. 1-2. Ellis, A. (1962). Reason andemotion in
psychotherapy, L.S., New-York. Jacoby, L. (1991). A Process Dissociation
Framework: Separating AutomaX from Intenional Uses of Memory, Journal
of Memory and Langual
30,513-514.
Johnson, M. H. (1994). Process of successful intenional forgettim
Psychological Bulletin, 2, 274-292. Kuhn, Th. (1976).
Structura revoluiilor tiinifice, Bucureti, Editu
tiinific i Enciclopedic.
Lewitcki, P. (1986). Nonconscious social Information processing, Academ
Press,San Diego. Miclea, M. (1994). Psihologie cognitiv, Cluj,
Editura Gloria. Miclea, M. (1996). Repression as Successfid Intenional
Forgetting, Cognii
Creier Comportament, nr.2. Smith, M. L., Glass, G. V., & Miller, T. I.
(1980). The benefiM psychotherapy, Baltimore, MD: John Hopkins
University Press.
52
Capitolul 3
TEHNICI DE INTER VENIE LA NIVEL
COMPORTAMENTAL
- Dan DA VID Chapter 3 is entitled "Intervention techniques at behavioral Level". In
this chapter, we present in detaisspecific operant techniques for
modifying operant behavior: (a) techniques for accelerating operant
behavior and (b) techniques for decelerating operant behavior. In
each case we offer clinical case examples from both our own clinical
practice and from literature.
Key words: operant behavior, behavioral therapy.
Cuvinte cheie: comportament operant, terapie comportamental.
n acest context, nelegem prin comportament acele reacii ale
organismului observabile i msurabile care au fost nvate n cursul
dezvoltrii ontogenetice (ex. scrisul, mersul, lovirea altei persoane, etccomportamente operante). Spre deosebire de behaviorismul clasic, nu
includem aici acele reacii ale organismului observabile i msurabile care
sunt nnscute (reflexe necondiionate, modificri ale sistemului nervos
vegetativ-comportamente respondente) i n cazul crora nvarea are loc
doar n sensul creterii spectrului de stimuli care le pot declana (ex.
condiionarea clasic).
Intervenia la nivel comportamental vizeaz modificri n
mecanismul 1.2.9. i 10.9. (vezi cap.l) i este ghidat de dou legi
importante.
-i
Regula 1 precizeaz c orice comportament este determinat de tecedente:
(1) stimuli externi; (2) stimuli interni - modificri fiziologice i /?wect've; (3)
prelucrri informaionale i este meninut de consecinele sale: ) ntriri pozitive;
(2) ntriri negative; (3) pedepse. Pentru a modifica un- mportament, trebuie
fcute modificri la nivelul antecedentelor i nsecinelor acelui comportament.
Altfel spus, orice comportament este erminat de procesri informaionale
amorsate de stimuli externi sau interni este meninut de consecinele sale.
53
eferitoare
COMPORTAMENTULUI
(a). Prin modificarea consecinelor: (1). Tehnica shaping^ftehnica
aproximrii). Shapingul se refer la aproximarea succesiv a unui
comportament dezirabil. El presupune doi pai:
descompunerea comportamentului adaptativ ce urmeaz a fi
accelerat n mai multe secvene;
ntrirea fiecrei aproximri succesive de comportament
adaptativ; dac ntrirea se face de la prima secven^ a
comportamentului spre ultima atunci vorbim de "forwardshaping".
Dac se face de la ultima ctre prima atunci vorbim de
"backwardshaping" 7~
Exemplu. Shaping pentru comportamentul de a mnca
(1). mprirea pe secvene: - a prinde lingura n mn,
- a lua sup cu lingura,
- a ridica lingura la gur,
- a introduce supa n gur.
(2). Se ntrete prima secven: apucarea lingurii (forwardshaping)
a
Poi se ofer ntrire doar dup prima i a doua secven etc.
In cazul backwardshaping-ului se ncepe cu ultima secven, se duce ungura
n gur, celelalte fiind executate de ctre terapeut. Ulterior, erapeutul execut
doar primele dou secvene etc. Indicaii: - n terapia copilului,
- tulburri grave n cazul adulilor ex. depresie sever,
demen, psihoze etc,
- deficien mental, autism.
. (2). Tehnica Premarck (Premarck este numele autorului acestei
tph
57
58
Capitolul 4
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
D3V,d
TEHNICI DE RELAXARE
Tehnicile de relaxare induc modificri la nivel biologic prin
modificarea balanei neurovegetative n sensul echilibrrii acesteia i scderii
dominanei sistemului nervos vegetativ simpatic. Acest fapt este benefic n
sensul c reduce parametrii psihofiziologici ai stresului i anxietii cu impact
pozitiv asupra tratamentului tulburrilor psihosomatice i recuperrii dup
stf
es i anxietate (Catania i Brigham, 1987).
Cele mai utilizate tehnici de relaxare sunt:
trainingul (antrenamentul) autogen,
relaxarea progresiv Jacobson,
tehnica biofeedback,
hipnoza (vezi partea a doua a lucrrii).
! Antrenamentul autogen
curs
62
Uri
67
Mecanismul biofeedback-ului
Prin tehnica biofeedback, subiectul nva s operaional^
conceptul de relaxare i/sau de modificare a unui parametru specificapariia ritmului alfa). Ulterior, ca urmare a exerciiilor repetate, se ntjj
conexiunea ntre eticheta lingvistic de relaxare i/sau modificare specif
starea efectiv pe care acestea o definesc, subiectul reuind astfel ;
controleze lingvistic i voluntar relaxarea muscular i/sau modific
specific.
Tehnica biofeedback este favorizat de urmtoarele premise:
(1) De cele mai multe ori o funcie intern a organismului nul
liniar, ea variind continuu ntre anumite limite; n momentul n I
terapeutul observ o variaie a funciei n sensul urmrit, va admin
ntririle care, conform legii efectului, vor duce la creterea frecv
modificrii dorite;
(2) Poziia aleas, nchiderea ochilor i condiiile de mediu ind
mod natural, prin mecanisme fiziologice specifice, o stare de reia
muscular. Exemplu: lipsa stimulrii proprioceptive intense (prin po
aleas) i a stimulrilor din mediu (prin nchiderea ochilor i organi
mediului) reduc activitatea formaiunii reticulate i gradul de stimulare,
care aceasta l exercit asupra scoarei cerebrale. n consecin, tonii
muscular se reduce i muchii se relaxeaz;
(3) n cazul n care dup mai multe ncercri modificarea dorit
apare sau nu se menine nici mcar un timp scurt, terapeutul poate schi)
uor (n sensul dorit i ateptat de subiect) i intenionat valoarea parametrii
contientizabil (ex. sunet) prin care funcia intern se exprim. Aceasta dr
la scderea anxietii de performan a subiectului, care adesea interfera
apariia modificrii dorite. Mai mult, pentru a stimula apariia modifi
dorite, terapeutul poate da pacientului sugestii asemntoare celor din ca
trainingului autogen; nu este ns indicat a se abuza de aceste form
deoarece astfel se elimin unul dintre aspectele fundamentale
biofeedback-ului, i anume acela care confer individului sentimentul
independen i autocontrol, cu efecte benefice asupra eficientei terapiei.
Tehnica biofeedback este indicat n special atunci cnd dorii
modificm preponderent un proces fiziologic-int. De asemenea,
indicat n cazul subiecilor cu o pregtire tehnic, n tiinele exacte.
Concluzie. Tehnicile de relaxare propuse se constituie n met
eficace de intervenie nu doar pentru remiterea simptomelor generate d
situaie anxiogen i/sau stresant, ci i pentru prevenirea acestora
mbuntirea performanelor subiecilor n situaii n care starea de relax
este un factor care poate crete eficiena (ex. performane sportive - tir
arcul etc).
70
73
BIBLIOGRAFIE SELECTIVA/SELECTIVE
REFERENCES
Capitolul 5
ANXIETATEA DIN PERSPECTIVA
TIINEI COGNITIVE
- Dan DAVID Chapter 5 is entitled "Anxiety and cognitive science". In this chapter,
we approach anxiety disorders from the cognitive science point of
view, analyzing anxiety atfour levels: cognitive, behavioral, biological
and subiective.
Key words: anxiety disorders, cognitive science.
Cuvinte cheie: tulburri de anxietate, tiine cognitive.
Procese
i
dezadaptative
Totdeauna n tot
ceea ce fac trebuie s
fiu primul, altfel
sunt incapabil i prost
Procese
i
coninuturi
dezadaptative
Totdeauna
Acum trebuie s
trebuie s fiu
controlez perfect
stpn pe mine i s
m controlez
Rezulta
coninuturi
j
La acest examen trebuie
s iau nota maxim i s fiu
cel mai bun, altfel sunt
incapabil i prost
1
distres
Rezulta
m
distres
76
b$*'"
'
Tabel 1.
vele subiectiv-cognitiv
comportamental
Trtprezena modificrilor la
nivelul respectiv
- lipsa unei modificri de intensitate contient i semnificativ (clinic)
Cel mai frecvent ntlnit tip de anxietate este tipul 1, el urmnd a fi tratat
n continuare. Patternurile 1, 4, 5 i 7 sunt cele care pe termen lung n condiiile
nerezolvrii tulburrilor de anxietate vor genera tulburri psihosomatice.
Pacieni care prezint patternurile 4 i 5 vor nega c sufer de anxietate, aceti
pacieni fiind ntlnii doar n seciile de interne, cardiologie, ginecologie,
urologie i nu la psihiatrie; psihoterapia acestor pacieni este dificil deoarece ei
nu accept cauza psihologic a problemelor lor organice. Dintre pacienii care
se prezint la psiholog sau la psihiatru (1, 2, 3, 7), o atenie deosebit trebuie
acordat patternurilor 1 i 7 deoarece nerezolvate i cronicizate pe termen lung,
tulburrile de anxietate vor fi dublate de tulburri psihosomatice. Patternul 6
este reprezentat de conversia motorie isteric n care apare paralizia meninut
de anxietate.
Oricum, dup cum aminteam mai sus, cel mai frecvent pattern ntlnit
n practica clinic este 1, de aceea acesta va fi tratat n cele ce
urmeaz.
Interaciunea acestor patru nivele d natere tulburrilor specifice de
anxietate conform DSM-IV. Nu se cunosc nc foarte precis mecanismele
Mime specifice prin care interaciunea celor patru nivele d natere unei
tulburri de anxietate specifice conform DSM. Studiile viitoare vor clarifica
cu
certitudine acest aspect datorit uriaelor sale implicaii teoretice i
P^gmatice.
Conform DSM-IV, tulburrile de anxietate apar sub urmtoarele
forme:
M fakzko
1
IO
8. stres acut,
9. anxietate generalizat,
10. anxietate datorit unor tulburri organice,
11. anxietate datorit consumului de substane chimice,
12. tulburri de anxietate nespecificate.
Criteriile de diagnostic pentru fiecare tulburare n parte sunt explic
prezentate n DSM-IV, astfel c nu are rost s le reproducem aici. Mai jfl
menionm principalele teste psihologice utilizate n diagnosticul anxietiB
care nu trebuie s lipseasc nici unui clinician. Ele mbogesc diagnostic
efectuat cu ajutorul DSM, relund aspecte noi, ascunse, specifice pacientului
i relevante pentru intervenia terapeutic. Altfel spus, ele obiectivizeaz
diagnosticul anxietii, cu implicaii pentru evoluia interveniei terapeutice ij
a cercetrii.
Cele mai utilizate teste psihologice n diagnosticul anxietii sunt:
Inventarul de anxietate STAI (State-Trait Anxiety Inventory),
anxietate).
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
David, D. (1999). Mecanisme incontiente de reactualizare a informaiilor, Tez
de doctorat, Universitatea "Babe-Bolyai", Cluj-Napoca.
Heap, M. (1991). Hypnotherapy, Open University Press.
Miclea, M. (1997). Stres i aprare psihic, Presa Universitar Clujean, ClujNapoca.
Capitolul 6
INTERVENIA COGNITIVCOMPORTAMENTAL N
TULBURRILE DE ANXIETATE I
PSIHOSOMATICE
Dan DAVID, Cristina POJOGA, Mihaela STNCULETE Chapter 6 is entitled "Cognitive-behavioral therapy in anxiety and
psychosomatic disorders". In this chapter, we present the way in
which certain packages of cognitive-behavioral techniques are used in
specific anxiety, sexual and psychosomatic disorders defined
according to DSM-IV.
Key words: packages of cognitive-behavioral techniques, specific
anxiety disorders, sexual disorders.
Cuvinte cheie: pachete de tehnici de intervenie cognitivcomportamental, tulburri de anxietate, tulburri sexuale.
Tehnicile de intervenie la nivel cognitiv, comportamental i biologic
prezentate n capitolele precedente au o aplicabilitate general n terapia
cognitiv-comportamental a ntregii patologii psihice i psihosomatice.
Totui, ele nu acioneaz separat ci se combin n pachete de intervenie
specifice pentru anumite tulburri psihice i psihosomatice. n continuare, yom
prezenta succint pachetele de tehnici cognitiv-comportamentale utilizate m
tratamentul tulburrilor de anxietate, sexuale i psihosomatice (conform DSM
IV), pornind de la cele mai cunoscute mecanisme etiopato genetice. Pentru
criteriile diagnostice i alte informaii legate de evoluia, prevalenta etc acestor
tulburri vezi DSM IV i ICD. "Noi nu prezentm aici aceste informaii din
raiuni de spaiu tipografic i datorit faptului c ele sunt bine sistematizate n
lucrri de referin cum este DSM spre exemplu. In continuare, aa cum
aminteam mai sus, vom prezenta sintetic doar modalitile de
intervenie cognitiv-comportamental presupunnd ns cunoscute aspectele
semnalate din DSM.
81
80
TULBURRILE DE ANXIETATE
___ .^UTUUJUJH un, ATNA1ETATE
Interveniile cognitiv-comportamentale n anxietate sunt ghidate
dou reguli extrem de importante. Prima regul se refer la faptul c nai de
intervenia psihoterapeutic este necesar un control medical pentru
identifica eventualele cauze medicale ale anxietii. In cazul n care acestea
identific, intervenia psihoterapeutic se combin cu tratamentul medical,
doua regul se refer la utilizarea tehnicilor de inoculare a stresului ("
Aproape oricare tulburare de anxietate primar are suprapus o tulbu
aqxielale, secundar;, altfel spus, subiectul devine mai anxios (anxie
secundar) cnd realizeaz c este anxios (anxietate primar). n ac context,
n tratamentul tulburrilor de anxietate, n pachetele de interveni cognitivcomportamental se afl aproape ntotdeauna tehnica de innocular stresului
(SIT-ul) pentru controlul anxietii secundare.
(1). Atacul de panic,
Mecanisme etiopatogenetice. Secvena mecanismelor eti
patogenefipe n atacul de panic este urmtoarea:
(1) apariia unei stri de arousal; aceast stare de arousal poate aj
o cauz fiziologic (sport, consum de cafea etc.) sau poate fi expresia u
dereglri la nivel biologic (ex. hipersecreie de adrenalin, noradrenalin);
(2) interpretarea negativ a acestei stri de arousal fiziologic
expresie a unei boli grave, ca un posibil stop cardiac, combinat cu ideea
lips a autocontrolului i de iminen a unei crizei;
(3) aceast interpretare amplific modificrile induse de SNV,
punctul (1), fntrndu-se ntr-un cerc vicios.
Pachete de intervenie cognitiv-comportamental: tehnici de relaxare i
control al respiraiei pentru a influena i controla starea de arousal fiziologic.
Pacientul trebuie nvat care suij indicatorii declanrii atacului de panic i
cum trebuie s se relaxeze momentul respectiv. Relaxarea nu are nici un efect
dac se ncearc obiner acesteia dup declanarea atacului de panic
deoarece simptomele anxietate sunt att de puternice nct nu pot fi anulate prin
tehnici de relax tehnici de restructurri cognitive prin care se atac
interpretarea la secvena (2); se insist asupra tehnicii de hiperventilaie
(pacientul este s inspire, i s exire__iagjd. i .adnc timp de dou
minute; ace hiperventilaie produce n fapt la nivel fiziologic aceeai
simptomatologie i atacul de panic) prin care pacientul i d seama c starea
de aro fiziologic este expresia hiperventilaiei, nu a unei boli ascunse.
Intervenia n situaia de criz
82
pacientul este rugat s respire ntr-o pung; aceasta are efect opus
hiperventilaiei (care amplific simptomele vegetative ale atacului de panic)
rin creterea concentraiei de C02.
pacientul este determinat s fac diverse activiti care prin
resursele cognitive pe care le angajeaz nu dau posibilitatea acestuia s-i
prelucreze negativ i catastrofic starea n care se afl (ex. s numere obiectele
din camer etc).
Tratament medicamentos
antidepresive triciclice (Imipramina, Clomipramina) i cele
tetraciclice sunt utile n acest tip de tulburare. Se recomand nceperea
tratamentului cu doze mici: 10-25 mg/zi, urmat de o cretere gradat a
acestora pn la 250-300 mg, ocazional chiar la doze mai mari.
inhibitorii de monoaminoxidaz (IMAO): ex. Fenelzina. Aceast
clas de medicamente este indicat de majoritatea studiilor ca fiind mai
eficient chiar dect antidepresivele triciclice dar nu reprezint n mod
necesar tratamentul de elecie datorit faptului c necesit o diet care s nu
conin alimente bogate n tiramin (brnzeturi fermentate, vin rou etc),
aceast combinaie producnd pusee hipertensive.
Efectele acestor dou clase de medicamente apar numai dup o
perioad de 2-4 sptmni.
benzodiazepme: ex. Alprazolam, Clonazepam. Reprezint a Jioua
linie de tratament deoarece la ntreruperea lor poate aprea rebound.
inhibitorii specifici ai receptorilor serotoninergici;
beta-blocante (ex. Propranolol)^ blocheaz palpitaiile i tremorul
din timpul atacului de panic, fiind utile doar n criz, nu i pentru prevenirea
atacului.
(2). Fobii simple
Mecanisme etiopatogenetice. Exist dou tipuri de fobii:
Mipl: cu cogniii dezadaptative,
>
^cAi,
tip 2: fr cogniii dezadaptative.
S>*-tj***A
OAAV.OCOQ
Fobia tip 1:
&;y
(a) stimulul fobie joac rolul stimulului condiionat iar reacia
anxioas reprezint rspunsuTrecondiionat,
(b) cogniiile dezadaptative (exagerate fa de stimulul fobie; ex.
Ini
i sunt animale periculoase, turbate etc.) amplific simptomatologia
anxioas i genereaz comportamentul evitant.
Pachete de intervenie cognitiv-comportamental tehnici de desensibilizare
progresiv i flooding, expunere gradat "loaelare- pentru componenta a)
83
88
89
Tratament medicamentos
benzodiazepinele (Diazepam, Alprazolam, Clonazepam) sunt
eficace. Efectul lor se instaleaz rapid, dar exist anumite reaciile adverse:,
tulburri de memorie, dezinhibiie, sedare, dependen (mai ales n cazul
Alprazolamului).
Buspirona este un anxiolitic nebenzodiazepinic eficient.
alfa
catecolaminelor
(adrenalin,
asupra
93
92
noradrenalina)
mtin^re Tabelul 1
Tabelul 1
Efectele catecolaminelor i receptorii prin intermediul crora se realizeaz aciunea
acestora (dup Gilman A.G., PI
Goodman L.S., Rall T.W. i colab., citai de Porth,
1990).
Organ efector
Ochi
-musculatura radiar a
irisului
-musculatura corpului ciliar
Inim
-nodul sino-atrial
Tipul de
receptor
al
P
PI
-atni
-nodul atrio-ventricular
PI
-reeaua Purkinje
PI
-ventriculi
PI
Arteriole
-coronare
a,S2
Aciune
-vasoconstricie, vasodilataie
(predominant) -vasoconstricie
a
a,P2
a, P2
-vasoconstricie, -vasodilataie
-vasoconstricie
(predominannt), vasodilataie vasoconstricie" uoar vasoconstricie, vasodilataie vasoconstricie, vasodilataie
a
a, P2 al,
01, 62
Plmni
-musculatura traheal i
bronic
-glande bronice
Stomac
-tonus i motilitate
-sfinctere
-secreie
Intestin
-tonus i motilitate
-sfinctere
-secreie
Vezic i canale biliare
Rinichi
Vezica urinar
-muchiul detrusor
-sfincter intem
Ureter: motilitate i tonus
Uter
-uter gravid
-uter negravid
Organe genitale masculine
Tegument
-muchi pilomotori
-glande sudoripare
Muchi scheletici
62
ocl,P2
a2,p2
a
(nu se cunoate)
ccl,pl,P2
a
(nu se cunoate)
P2PI
Pa
GP2
P2
a
".rcSa/creter-secreiei
-de obicei inhib^. de obicei contrictie inhibare?
-de obicei inhib^. de obicei contfWe inhibare?
iSea sectei de renin
-de obicei reia*316
-contracie
-cretere
-contracie (a), taxare (P2)
-relaxare ejaculare
-contracie .
creterea con1
glicogenoliz
-glicogenoliz^_
gluconeogenza
-^f^tSlitii, -
a
P2
a,p2
Ficat
a a2,P2
Pancreas
-acini pancreatici
-insule Langerhans (celule
beta)
Adipocite
Glande salivare
a,pi al
P P 61
Epifiza
Hipofiza posterioar
ce ef,z,0l
*l
Hiherareadedecanma,
cantiti de catecolarmne ma.^ mari dect
' f'Vscheletici i ficat, i
la eliberarea
^ ^ muchi.
Uof viscere
Tabelul 2
esut adipos
Sistem
muscular
-stimularea catabolismului
protidic
-scderea sintezei fibrelor
colagene
Sistem osteo- -reducerea absorbiei de calciu
articular
i fosfai cu eliminarea lor
urinar
-inhibarea osteoblatilor
-reducerea sintezei matricei
proteice
Aparat
-bronhodilataie
respirator
-inhibarea macrofagelor,
inhibarea fagogitozei la nivel
local
-scderea secreiei de mucus
Aparat cardio- -creterea debitului cardiac
vascular
-creterea responsivitii
peretelui arterial la aciunea
catecolaminelor
-hipervolemie (prin retenfie de
sodiu i ap i prin
poliglobulie)
96
-favorizarea diseminrii
infeciilor
-reducerea elasticitii
parenchimului pulmonar
-hipertensiune arterial favorizarea instalrii edemelor
n insuficiena cardiac
Snge
-reducerea chemotaxisului
leucocitar i a fagocitozei poliglobulie hipercoagulabilitate
Tub digestiv
Ficat
Aparat urogenital
Sistem nervos
Sistem imunitar
97
Componente
psihofiziolologice
normale ale
reaciei
-tahicardie
-fluctuaii
tensionale
Aparat respirator
-polipnee
-tahipnee
Aparat digestiv
-inapeten
-senzaie de jen
epigastric
-grea
Aparat urinar
-polakiurie
-poliurie
Aparat
locomotor
-senzaia de
tensiune muscular
Sistem endocrin
-reacii diencefalohipofizare
-descrcare
catecolaminic
-tremor
Sistem nervos
Aparat genital
-secreii ale
mucoaselor
-erecie
Tulburri
funcionale
-palpitaii
-lipotimii
-sincope
-hiper sau
hipotensiune
-dispnee nevrotic
-senzaia de
opresiune toracic
-bulimie /
inapeten
-spasme
-diaree /
constipaie
-retenie urinar
-enurezis -cistalgii
cu urini clare
Boli
psihosomatice cu
leziuni organice
-tahicardie
paroxistic
-coronaropatii
-hipertensiune
arterial
-astm bronic
-boal ulceroas
-sindromul
intestinului iritabil
-rectocolit
ulcerohemoragic
?
-curbatur
-cervicalgii i
lombalgii -astenie
muscular
-amenoree
-dismenoree
-hipoglicemie
-poliartrita
reumatoid
-cefalee epilepsie
"funcional" hiperestezii
-impoten
-frigiditate
-vaginism sterilitate
-migrena
98
-hipertiroidism
-tulburri de
dinamic sexual
-ovarit
sclerochistic
Aparat vizual
Tegumente i
mucoase
Tulburri
Boli
Componente
funcionale psihosomatice cu
psihofiziolologice
leziuni organice
normale ale
reaciei
-glaucom
-hipersecreie
lacrimal -paloare
-roea -senzaia -prurit generalizat -urticarie
-angioedem
de cldur sau frig sau localizat
-eczema
-psoriazis
-modificri ale
-neurodermita
vocii
-afonie, disfonie - -rinit vasomotorie
-senzaia de "nod
strnuturi n salve -vertij
Sfera ORL
I. APARATUL RESPIRATOR
ASTMUL BRONIC
Definiie. Astmul bronic reprezint o afeciune inflamatorie cronic
a cilor aeriene la care particip multiple celule, printre care mastocite i
eozinofile. La persoanele susceptibile, aceast inflamaie cronic produce
simptome care sunt de obicei asociate cu obstrucie difuz dar variabil, a
cilor aeriene, adesea reversibil spontan sau prin tratament i determin o
cretere a reactivitii cilor aeriene la o varietate de stimuli (Gherasim,
1995). Obstrucia se manifest clinic prin accese paroxistice de dispnee cu
wheezing (respiraie uiertoare) i ruse.
Etiopatogenie. Sub aspect etiopatogenetic se descriu dou tipuri de
astm bronic (AB): alergic (extrinsec) i non-alergic (intrinsec). Astmul nonalergic cuprinde acele forme de AB n care pe primul plan sunt situate
mecanismele nervoase. Caracteristicile acestor dou tipuri de astm sunt
prezentate n urmtorul tabel.
Tabelul 4
__________ Criterii de difereniere ntre AB alergic i AB intrinsec. __________
Criterii de difereniere
AB alergic
AB intrinsec
Debut
precoce (sub 35 de ani)
peste 30-35 de ani
Antecedente personale i
boli alergice
nu se identific
heredocolaterale
elemente de alergie
Imunologie
IgE serice crescute
IgE serice normale
Teste cutanate
la injectarea intradermic reacie negativ
de alergen se produce o
reacie intens pozitiv
Factori declanatori
antigene specifice (de
factori psihologici
obicei inhalate)
(anxietate, stres,
conflicte), infecii,
poluani atmosferici,
__________________________________________ profesionali _________
n patogeneza AB pot interveni att o reacie imun ct i un
dezechilibru la nivelul sistemului nervos vegetativ (SNV) (Porth, 1990).
(a) Rspunsul imun. Astmul alergic se produce n principal printr-un
mecanism de hipersensibilitate de tip I mediat de anticorpi din clasa IgE.
Acetia sunt sintetizai n organism n urma unui prim contact cu alergenul,
dup care se fixeaz pe mastocitele din lumenul bronic. La apariia aceluiai
antigen se declaneaz o reacie antigen-anticorp urmat de activarea
mastocitelor i eliberarea mediatorilor chimici coninui n acestea (histamin,
adenozin, enzime etc). Aceste substane produc bronhospasm, creterea
100
/''. v'
102
Tratament.
Tratamentul medicamentos n criza astmatic const n:
A. Medicaie bronhodilatatoare:
(a) agoniti beta-adrenergici: reprezint prima linie de tratament.
Aceti agoniti pot fi:
cu durat scurt de aciune (2 ore): ex. Izoproterenol,
cu durat medie de aciune (4-6 ore): ex. Salbutamol,
cu durat lung de aciune (12 ore): ex. Formoterol.
(b) metilxantine: ex. Teofilin, Aminofilina,
(c) anticolinergice: ex. Bromura de ipratropium. B.
Antiinflamatoare: (a) corticosteroizii: reprezint cea mai
eficient medicaie
antiinflamatoare. Se administreaz:
-sistemic: ex. Prednison, Prednisolon,
-inhalator: Beclomethason dipropionat.
(b) antiinflamatoare nesteroidiene utile n prevenirea crizelor de AB:
Cromoglicatul de sodiu, Nedocromilul sodic.
Tratamentul de baz este tratamentul medicamentos, psihoterapia
fiind adjuvant.
Tratament psihologic.
Crizele astmatice nu pot fi tratate exclusiv prin metode
psihoterapeutice, ele necesitnd tratament medicamentos, dar psihoterapia
este util n scderea anxietii care nsoete crizele (i care determin
exacerbarea manifestrilor specifice) i identificarea cauzelor psihologice
care condiioneaz, preced i declaneaz crizele astmatice.
Tratamentul psihologic de fond (pentru reducerea anxietii cronice),
n acest scop se utilizeaz tehnici prin care intervenia se realizeaz la trei
nivele: cognitiv, comportamental i biologic.
(1) Tehnicile de intervenie la nivel cognitiv (tehnici de restructurare
cognitiv, tehnici de inoculare a stresului i tehnica rezolvrii de probleme)
(vezi cap. 2).
(2) Tehnicile de intervenie la nivel comportamental (tehnici de
accelerare, respectiv decelerare a unui comportament) (vezi cap. 3).
(3) Tehnicile de intervenie la nivel biologic: tehnici de relaxare,
flooding, desensibilizarea progresiv, biofeedback-ul, medicaia anxiolitic
(ex. Diazepam, Distonocalm etc.) (vezi cap. 4).
n afara acestor tehnici psihoterapeutice care se adreseaz fondului
de anxietate, sunt necesare i anumite intervenii cerute de particularitile
acestei boli.
Intervenii psihoterapeutice ce vizeaz boala int.
(1) Tehnici de relaxare. Acestea sunt utile n special la copii, avnd
succes mai ales n stadiile iniiale ale bolii. Se folosesc diverse tehnici:
103
104
XA =
Rezistena
Debitul cardiac
SNV simpatic
Mecanismul reninangiotensin-aldosteron
Figura 1. Factorii care determin valoarea tensiunii arteriale i mecanismele lor de
Volumul
sistolic
Frecvena
cardiac
Calibrul
vascular
Integritatea peretelui
vascular
control.
Orice condiie care determin hiperreactivitate simpatic determin
creteri tranzitorii ale tensiunii arteriale la o persoan normal i creteri
paroxistice ale tensiunii pe fondul unei hipertensiuni arteriale stabile.
SNV simpatic produce prin stimularea receptorilor alfal
vasoconstricie - ceea ce duce la creterea rezistenei periferice -, prin
stimularea receptorilor betal cardiaci produce creterea debitului cardiac, iar
prin stimularea receptorilor betal renali determin hipersecreie de renin. De
asemenea, sistemul vegetativ simpatic poate activa sistemul reninangiotensin-aldosteron (RAA) care produce mrirea tensiunii arteriale fie
prin vasoconstricia indus de angiotensina II, fie prin expansiunea de volum
determinat de aldosteron.
n clinic exist o strns relaie ntre factorii psihostresani i
creterile temporare ale tensiunii arteriale, iar la persoanele hipertensive
acetia produc invariabil oscilaii presionale mai ample i mai durabile.
Fenomene inverse se produc n condiii de relaxare i linite. Numeroase
studii experimentale atest rolul situaiilor psihostresante n apariia
hipertensiunii arteriale eseniale. S-a demonstrat existena unui rspuns
hipertensiv la stimuli ce declaneaz ostilitatea, furia sau anxietatea. Goldstein
(1981) a artat c hipertensivii rspund att la anxietate ct i la furie prin
creteri semnificativ mai mari ale tensiunii arteriale comparativ cu
normotensivii. Prin observaii clinice s-a confirmat faptul c cele mai des
identificate stri afective ale hipertensivilor sunt anxietatea, ostilitatea i furia.
105
mixte: Urapidil
(3) vasodilatatoare directe musculotrope (scad rezistena periferic):
Minoxidil, Diazoxid, Nitroprusiat de sodiu.
(4) inhibitorii enzimei de conversie (inhib sistemul renin-
Mediu
Ereditate
Predispoziie Creterea
debitului cardiac
i
i
HTA de grani
Creterea
rezistenei periferice
i
i
HTA stabilizat
Ateroscleroz
Complicaii.
(1) Datorate HTA: accident vascular cerebral hemoragie, insuficien
cardiac, insuficien renal, disecie de aort.
(2) Datorate aterosclerozei: cardiopatie ischemic (inclusiv infarct
miocardic), accident vascular cerebral ischemic, arteriopatii aterosclerotice periferice.
Tratament.
Tratamentul medicamentos. Mijloacele de tratament medicamentos sunt
reprezentate de 7 clase de medicamente (Gherasim, 1996).
(1) diuretice (reduc debitul cardiac):
tiazidice: Hidroclorotiazida, Clortalidona
de ans: Furosemid, Acid etacrinic
economizoare de potasiu: Spironolacton, Amilorid, Triamteren
(2) inhibitoare ale simpaticului:
inhibitori adrenergici periferici: Guanetidina
inhibitori adrenergici centrali: Alfametildopa, Clonidina
inhibitori adrenergici periferici i centrali: Rezerpina
alfablocante: neselective (Fenoxibenzamina), selective (Prazosin)
betablocante: neselective (Propranolol, Sotalol), selective
(Metoprolol, Atenolol)
alfa i betablocante: Labetalol
106
de
accelerare
comportamentelor
sntoase i de
decelerare
109
114
Complicaii.
(a) Locale: perforaia, megacolonul toxic, supuraii, hemoragii
masive, malignizarea leziunilor (de 30 de ori mai frecvent i cu 10 ani mai
devreme n cazul RCH dect la restul populaiei).
(b) Generale (mai rar ntlnite): manifestri articulare, cutanate
(pioderma gangrenosum), hepatice.
Tratament.
Tratamentul medicamentos se adreseaz n primul rnd puseului, cu
individualizri n funcie de gravitate i de prezena complicaiilor locale.
Tratamentul utilizeaz:
(1) antiinflamatoare: corticosteroizi de obicei n perfuzie (derivai de
prednison, hemisuccinat de hidrocortizon) sau n clism dac bolnavul le
tolereaz (Prednisolon 2, 1 fosfat, sau preparate superioare: Beclometazona,
Budesonid). Dup mbuntirea strii pacientului se poate trece la
administrarea de Salazopirin;
(2) antibiotice: Tetraciclin, Tobramicin. Administrarea lor evit
intervenia chirurgical la 4 din 5 bolnavi (Pascu, O., 1996);
(3) imunosupresoare: se administreaz n cazul n care nu se obin
ameliorri dup tratamentul cu antiinflamatoare: Azatioprina, 6
Mercaptopurina.
Tratamentul chirurgical n cazul instalrii anumitor complicaii
(supuraii, perforaii, megacolonul toxic) este necesar intervenia
chirurgical. Aceasta const n colectomie i determin creterea ratei
supravieuirii i a calitii vieii.
Tratamentul psihologic.
Tratamentul psihologic cuprinde tratamentul de fond al anxietii
(vezi capitolul "Astmul bronic").
Datorit puternicei influene a factorilor psihologici n declanarea
puseelor colitice precum i n evoluia general a bolii, se impune ntr-o
msur mai mare dect n alte stri patologice o abordare psihoterapeutic a
acestor bolnavi. Tratamentul psihologic adresat bolii int const n:
(1) n cazul acestei boli sunt importante tehnicile suportive, i
implicarea familiei astfel nct s se asigure bolnavului un mediu adecvat;
(2) Tehnicile comportamentale asociate cu interveniile la nivel
cognitiv au ca obiectiv schimbarea stilului de via al bolnavilor. n pusee este
necesar o alimentaie care s nu produc iritarea termic, chimic sau
mecanic a mucoasei. Trebuie scoase din alimentaie laptele, smntn,
brnzeturile fermentate, sucurile, dulciurile, legumele i fructele crude,
grsimile animale i grsimile prelucrate termic. Dup remisia puseului,
115
117
postoperatorii.
V. MIGRENA
Definiie. Migrena este o cefalee hemicranian, pulsatil, frecvent
nsoit de grea i vom; apare de obicei la copii i aduli tineri, disprnd la
vrste naintate.
La femei este de trei ori mai frecvent dect la brbai. Are tendina
s apar n cadrul sindromului premenstrual i n cazul reteniei hidrosaline i
s dispar n graviditate. Antecedentele heredocolaterale sunt prezente la 60%
din cazuri.
Etiopagenia. Mecanismul de producere nu este nc descifrat pe
deplin.
Faza prodromal reprezentat de semnele neurologice este rezultatul
scderii fluxului sangvin cerebral datorate vasoconstriciei arteriale. Se
consider c n aceast faz un rol important revine eliberrii de
noradrenalin i serotonin. Ulterior se presupune c arteriolele se dilat
excesiv, acest lucru conducnd la apariia durerii pulsatile. Acest mecanism i
confer denumirea de cefalee vascular.
Factorii declanatori ai crizei migrenoase sunt: stresul psihic,
anxietatea, menstruaia, contraceptivele orale, oboseala, privarea de somn,
foamea, traumatismele cranio-cerebrale, alimentele ce conin nitrii, glutamat,
sare, tiramin (ciocolat, vin rou, brnzeturi fermentate), modificri de
temperatur i de vreme.
Dup majoritatea autorilor, exist patru tipuri de migren (Wilson i
Braunwald, 1991).
migrena clasic: ncepe cu un prodrom n care predomin semnele
neurologice: fotofobie, tinitus, scintilaii vizuale, scotoame, hemianopsie.
migrena comun: nu este precedat de prodrom; apare numai
durerea nsoit sau nu de grea i vom.
Ambele tipuri rspund la tratamentul cu preparate de ergotamin dac acestea
sunt administrate n fazele iniiale ale crizei migrenoase.
migrena complicat: este o cefalee nsoit de semne neurologice
care pot s precead sau s nsoeasc cefaleea: parestezii, pareze, paralizii,
tulburri afazice. Pareza poate s se extind dintr-o regiune a corpului n alta
ncet n cteva minute. De obicei se realizeaz o recuperare total n cteva
minute sau ore. Totui, uneori este urmat de deficite permanente:
hemianopsie (leziuni n teritoriul arterei cerebrale posterioare), hemiplegie,
hemianestezie (leziuni n teritoriul arterei cerebrale medii), oftalmoplegie
(lezarea nervului oculomotor comun).
119
120
DISCUII
Abordarea din perspectiv psihosomatic a diverselor tipuri de
afeciuni permite decelarea unor simptome psihosomatice, altfel greu
interpretabile n afara considerrii substratului psihologic i dificil de tratat n
cazul considerrii lor ca simptome pur somatice, expresie a modelului
biomedical.
De aceea este necesar s se in cont n orice afeciune de rolul mai
important sau mai redus dar favorizam al factorilor psihologici n geneza
oricrei boli, avnd n vedere c determinanii psihologici sunt cofactori,
mpreun cu factorii genetici, constituionali, nutriionali etc. acionnd
convergent asupra organismului uman, rol exprimat n tratamentul aplicat n
cadrul bolii de ctre echipa terapeutic interdisciplinar.
Ct privete acest aspect n abordarea problematicii patologiei exist
dou modele fundamentale: modelul biomedical i modelul biopsihosocial.
(/) Modelul biomedical. Are tradiia cea mai mare n cultura
european. Este un model "infecios", impunndu-se odat cu descoperirile
lui Pasteur i Koch din domeniul microbiologici. Acetia au demonstrat c n
producerea bolilor infecioase sunt implicate microorganismele. Pornind de la
aceste descoperiri, s-a considerat c toate bolile au o cauz unic. Deci n
explicarea lor este suficient un singur mecanism cauzal, fr a se lua n
considerare mecanisme de alt natur.
David McClelland (1985) afirma despre modelul biomedical:
"Organismul este tratat ca o main care este reparat prin ndeprtarea sau
nlocuirea componentelor defecte sau prin distrugerea organismului strin ce
a produs boala".
Dezavantajele acestui model sunt prezentate n continuare.
1. Nu promoveaz meninerea strii de sntate i prevenia
mbolnvirilor.
2. Nu implic responsabilitatea individual pentru propria sntate.
3. Implic costuri ridicate deoarece se preocup numai de tratarea
bolilor, nu i de profilaxia lor; de asemenea exagereaz rolul tehnologiilor
costisitoare n diagnosticul i tratamentul bolilor.
4. Multe dintre tehnicile de investigaie utilizate sunt invazive,
presupunnd riscuri pentru pacient.
5. Nu ia n considerare impactul psihologic al bolii i al tratamentului
asupra pacientului i asupra familiei sale.
Este evident c factorii biologici ce influeneaz riscul apariiei unei
boli intervin doar ntr-un numr sczut de cazuri de boal. S-a constatat c
expunerea la un agent patogen la unele persoane determin boala, n timp ce
la altele nu. De asemenea este dovedit c factorii psihologici influeneaz
121
sntate
SELECTIV/SELECTIVE
fa CFERENCES
^>.
Sl
bioiog:
paradigm
n
domeniul
patologiei.
Iniierea
acesteia
^(JH
psihosomatic,
care
studiaz
interaciunea
factorilor
p&
\yji
n sntate i boal.
,:oat-' nUmite Psinosomati
ce.
(2) Modelul bio-psiho-social
,oe-e-Ulpufuri,e SenzoriaI,
psiholo
Ader (1980) afirma c toate bolile pot fi twrjfgj^b
gici j S0C]. deoarece
creierul recepioneaz i interpreteaz toate inpU | , ." Altfel spus, facto
Deja s-a demonstrat c factorii biologici, |> J e 1J0ac un rol important
interacioneaz n influenarea strii de sntate i a bolii, jlf M- dpsihologici i sociali influeneaz funciile biologice ijo^j//.ne
' a Sntii (1946)
n meninerea sntii i apariia bolii.
H
^ sociaI, i nu numai
Definiia sntii conform Organizaiei Mondial y/l este: "Sntatea reprezint
starea de bine fizic, mental i Ji'. Pectui biomedical, ci dea
'ltoor.iimPortanicarenu
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
lovschi, M. (1996). Sindromul intestinului iritabil, In Grigorescu, M.,
Pascu, O., Tratat de gastroenterologie clinic, voi. I, Editura
Tehnic, Bucureti.
Ader R- (1980/ Psychosomatic and psychoimmunologic research,
Psychosomatic Medicine, 42, 307-321. Andreica, V., & Andreica, M.
(1995). Infecia cu Helicobacter pylori n bolile
stomacului i duodenului, Editura Hippocrate, Sibiu. Burke, D. A.,
Axon, A. T. R., & Klayden, S. A. (1990). The efficacy of
Tobramycin in the treatment of ulcerative colitis, Aliment. Pharm.
Ther, 4:123.
Engel, G. L. (1975). Psychological Aspects of Gastro-lntestinal Disorders, In
Arieti, S. "American Handbook of Psychiatry", Basic Books, New
York, pg. 653-692.
Engel, G. L. (1977). The need for a new medical model: A challenge for
biomedicine, Science, 196, 129-135. Gherasim, L. (1995). Medicin
intern, Bolile aparatului respirator. Bolile
aparatului locomotor. Voi. I. Editura Medical, Bucureti. Gherasim, L.
(1996). Medicin intern. Bolile cardiovasculare. Bolile
metabolice.. Voi. II. Editura Medical, Bucureti. Glaser, R., & KiecoltGlaser, J.K. (1994). Handbook of Hutnan Stress and
Imunity, Academic Press Inc., San Diego. Goldstein, B. (1981). Assessment of
Hipertension. n Prokop, Ch. K., Bradley, L.A., Medical Psychology,
Academic Press, New-York, Pg-37-54.
roen, J. J. (1976). Present state of the psychosomatic approach to bronchial
asthma. In Hill, O. Modern Trends in Psychosomatic Medicine, voi.
3, London: Butterworth.
amandescu, I. B. (1997). Psihologie medical, Editura Infomedica,
Bucureti.
onescii, G. (1990). Psihoterapie, Editura tiinific, Bucureti, -lelland, D. C.
(1985). The social mandate of health psychology, Gf.
American Behavioral
Science, 28, 451-467.
'gorescu, M., & pascu, O. (1996). Tratat de Medicin Intern.
Gastroenterologie, Clinic Voi. I, Editura Tehnic, Bucureti.
123
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Acalovschi, M. (1996). Sindromul intestinului iritabil, n Grigorescu, M.,
Pascu, O., Tratat de gastroenterologie clinic, voi. I, Editura
Tehnic, Bucureti. Ader, R. (1980). Psychosomatic and
psychoimmunologic research,
Psychosomatic Medicine, 42, 307-321. Andreica, V., & Andreica, M.
(1995). Infecia cu Helicobacter pylori n bolile
stomacului i duodenului, Editura Hippocrate, Sibiu. Burke, D. A.,
Axon, A. T. R., & Klayden, S. A. (1990). The efficacy of
Tobramycin in the treatment of ulcerative colitis, Aliment. Pharm.
Ther, 4:123.
Engel, G. L. (1975). Psychological Aspects of Gastro-lntestinal Disorders, n
Arieti, S. "American Handbook of Psychiatry", Basic Books, New York, pg.
653-692. Engel, G. L. (1977). The need for a new medical model: A challenge
for
biomedicine, Science, 196,129-135. Gherasim, L. (1995). Medicin
intern, Bolile aparatului respirator. Bolile
aparatului locomotor. Voi. I. Editura Medical, Bucureti. Gherasim,
L. (1996). Medicin intern. Bolile cardiovasculare. Bolile
metabolice, Voi. II. Editura Medical, Bucureti. Glaser, R., &
Kiecolt-Glaser, J.K. (1994). Handbook of Human Stress and
Imunity, Academic Press Inc., San Diego. Goldstein, B. (1981). Assessment
of Hipertension. n Prokop, Ch. K., Bradley, L.A., Medical Psychology,
Academic Press, New-York,
pg.37-54. Groen, J. J. (1976). Present state of the psychosomatic
approach to bronchial
asthma. n Hill, O. Modern Trends in Psychosomatic Medicine, voi.
3, London: Butterworth. Iamandescu, I. B. (1997). Psihologie
medical, Editura Infomedica,
Bucureti. Ionescu, G. (1990). Psihoterapie, Editura tiinific,
Bucureti. McClelland, D. C. (1985). The social mandate of health
psychology,
American Behavioral Science, 28, 451-467. Grigorescu, M., &
Pascu, O. (1996). Tratat de Medicin Intern.
Gastroenterologie, Clinic Voi. I, Editura Tehnic, Bucureti.
123
Capitolul 7
NOI PERSPECTIVE N
TRATAMENTUL ANXIETII;
BOMBARDAMENTUL SUBLIMINAL
- Dan DAVID, Adrian OPRE In this chapter entitled "Subliminal stimulation and the treatment of
anxiety" we present in a synthetic nianner the fundamental
assumptions and the results of implicit (subliminal) perception studies
and the way these can be used as a clinical tool in the treatment of
anxiety (e.g. subliminal systematic desensitization; Silverman's
procedures etc). We argue that more must be done for obtaining
ecological subliminal exposure techniques useful in clinical practice.
Key words: subliminal perception, anxiety, clinical intervention.
Cuvinte cheie: percepie subliminal, anxietate, intervenie clinic.
130
APLICAII N PSIHOTERAPIE
Nucleul de rezultate teoretico-experimentale prezentat mai sus a
avansat ideea unor aplicaii n domeniul clinic. Aceasta deoarece multe
cercetri de psihologie clinic au artat c simptomatologia unor pacieni este
expresia unor prelucrri incontiente de informaie. Spre exemplu, n anxietate
apare tendina incontient de a prelucra preponderent din realitate stimulii
anxiogeni; aceasta n consecin amplific anxietatea, care apoi la rndul ei
favorizeaz prelucrarea preponderent din realitate a stimulilor anxiogeni.
Intrm astfel ntr-un cerc vicios care amplific simptomatologia. Aceste
prelucrri incontiente ar putea fi modificate prin stimulare
subliminal.
Primele aplicaii n domeniu au demarat n paradigma psihanalitic.
Se consider c simptomatologia este expresia unui conflict actual
incontient, conflict ce se reduce de fapt la un conflict bazai din copilrie,
viznd n special persoanele semnificative (ex. dorin incestuoas n
homosexualitate, agresivitate reprimat n depresie, agresivitate oral n
schizofrenie etc). Stimularea subliminal ar putea influena dinamica acestor
conflicte, reducnd astfel simptomatologia. Mesajul subliminal cu cel mai mare
impact n reducerea simptomatologiei s-a dovedit a fi "Mom and I are one-eu i
mama suntem una". Aceasta deoarece mesajul are un rol simbiotic, rezolvnd
presupusele conflicte ale individului cu persoane semnificative n copilrie,
conflicte n care era implicat n special mama. Acest mesaj, expus subliminal
(20 de stimulri de 4 ori pe sptmn) s-a dovedit util n reducerea
simptomatologiei n anxietate, schizofrenie, stres, obezitate, n creterea
performane colare etc. Un alt mesaj subliminal: "Beating dad is O.K.-a-i bate
tata este un lucru bun" care se presupune c acioneaz i rezolv conflictul
Oedip are un efect benefic asupra performanelor n condiii de competiie (ex.
tir cu arcul etc). Spre deosebire de mesajul "Beating dad is wrong-a-i bate tata
este un lucru ru" care, acutiznd complexul Oedip, reduce performanele n
condiii de competiie. Aceste mesaje prezentate supraliminal nu au efectele
prezentate mai sus deoarece, consider autorii, prezentarea supraliminal
declaneaz mecanismele de aprare care mpiedic reprezentarea lor adecvat
n memorie i n dinamica conflictului incontient. Orict ar prea de ciudate
aceste rezultate obinute ca urmare a unui angajament psihanalitic, ele au fost
confirmate de studiile moderne de metaanaliz. Recent s-a ncercat
reinterpretarea acestor rezultate ntr-un cadru teoretic tiinific, dincolo de
perspectiva psihanalitic cu tent de mit. Aceasta poate duce la clarificarea
mecanismelor implicate i la potenarea efectului lor. Rezultatele acestor
interpretri le prezentm n continuare.
(a) S-a demonstrat c aproximativ aceleai efecte se obin chiar dac
nu afim subliminal ntregul coninut stabilit de psihanaliti, ci doar pri din
131
132
133
Chapter 8
ANXIETY PREVENTION
A THEORETICAL FRAMEWORK FOR
MENTAL HEALTH PROMOTION
new public
Bunton and
Health promotion, which emerged in the 1990s, has become an essential force
of the new science of prevention and it is an important feature of the contemporary
approaches to health and health care provision. Its development seems to have sprung
from the increasing dissatisfaction with the biomedical model of aetiology, diagnosis,
and treatment of disease. The biomedical model of mental illness ignores the far more
complex social issues individuals face in the world, such as employment (or
unemployment), housing (or homelessness), low income or cultures engendering
behavior harmful to health; the biomedical model of mental health somehow separated
the soma from the psyche, the disease from the patient, the patient from the society in
which he/she lives.
The new paradigm of prevention introduces the idea that all diseases and
causes of death could be attributed to four discrete elements:
(1) lifestyle (behavioral and psychological factors)
(2) bio-physical characteristics
(3) environmental characteristics
(4) inadequacies in health care services.
As a result of the new ftndings, many governments from different countries
shifted away the emphasis from treatment to prevention of illness
135
134
I Health Promotion
1980's-2000
Epidemiology of
mental health
Educaional
science
Psychology
Sociology
Psychiatry
Social policy
Communication
sciences
etc.
I ______
Evaluation
137
136
h sica,
Table 1.
Some generic risk factors for mental disorders
Emoional Diffculties
Family Circumstances
Child abuse
Low social class
Emoional blunting
Family conflict
Stressful life events
Family dissolution
Emoional dyscontrol
Large family size
Mental illness in the family
Cornmunication deviance
Unsupportive family atmosphere
High criticism _______________
Work Circumstances School
Academic failure
Circumstances
Scholastic demoralization Role ambiguity
Authoritarian relations Role conflict
High competitivity
Role overload
Uncontrollable environmental
Hazard conditions
Bureaucracy
The threat of unemployment
Jnerpersonal Problems Constitutional/Biological Factors
Neurochemical
Peer rejection imbalance Low social
Hypoglycemia
support Isolation and alienation Cardiac
Hyperthyroidism
disorders Withdrawal state
Ecological context
Ethnic and racial injustice
Extreme poverty Unsafe
neighborhood
(5) Risk factors must be addressed before they stabilize as predictors of
dysfunction. Preventive intervention should occur before the first onset of mental
dysfunction; with early intervention, there is a greater chance of preventing disorder.
Age of onset is often correlated with the severity of anxiety.
(6)Promoting proiective factors against risk factors. The effects of exposure
to risk can be mitigated by a variety of individual and social characteristics that serve
protective functions. Protective factors interact with the risk factors to buffer their
effects, disrupt the mediational chain through which the risk factors operate to cause
anxiety. Prevention science should advance our knowledge about protective factors.
Antonovsky (1987) used the term salutogenesis to refer to etiologic processes that
enhance emoional and
138
wnintable2.
Table 2.
Protective factors
======= Psychological
Senseofcoherence
Hardiness
Self-esteem
Optimism
Health locus of control
,.'.._,
Self-efficacy (e.g. safe sexual behavior)
Creativity
Extroversion resources
Behavioral
Dietary regimens
Exercise patterns
Sleep patterns
Smoking, alcohol consumption
Safety practices
Compliance with prescribed medical
regimens
Interpersonal skills
Use of community health services and
140
community accept the information, transmission and adoption are rapid until
only a minority of individuals fail to adopt the message of information (e. g.
the positive effects of exercise on depressive mood).
Clearly, none of the theories described above provides a full
explanation of health promotion. However, they do suggest key variables of
disease prevention programs, and rather than treat them as abstract and
separate theories, a synthesis of these models may provide a strong basis to
any health promotion iniiative.
In conclusion, psychologists could have a greater impact in mental
disorders prevention by reducing the psychosocial risk factors. This could
consist of a multidimensional approach. First, psychologists could work to
alleviate, where possible, the stressful conditions in the environment that
contribuie to the onset of psychological dysfunction; second, psychologists
could work to promote the mental health of the population at large, and to
increase people's resiliency in the face of stressful conditions that cannot be
eliminated; third, psychologists can identify people at risk of developing
emoional disorders and attempt to reduce stress that might contribute to the
onset of a disorder by providing education and support in crisis; and fourth,
psychologists can treat current symptoms of anxiety or other form of negative
affect, can prepare patients to become more resilient to better cope with future
stress (Fontana, 1989).
There is a criticai need that psychologists become more active in the
prevention of mental health problems. Because psychology offers a wide
range of theories, models and repertoire of applications, it has unique
contributions to prevent, treat and manage mental illness through research,
assessment and intervention. Obviously, psychologists are well prepared to
make substanial contributions in these areas.
144
SELECTIVE REFERENCES/BIBLIOGRAFIE
SELECTIV
Abramson, L., Seligman, M., & Teasdale, J. (1978). Learned helplessness in
human: critique and reformulation, Journal of Abnormal
Psychology, 87, 49-74. Ajzen, J., Fishbein, M. (1980). Understanding
Attitudes and Predicting
Behavior, New York: Prentice-Hall. Antonovsky, A. (1987).
Unraveling the Mistery of Health,. San Francisco:
Jossey-Bass. Bandura, A. (1977). Social Learning Theory, New York:
Prentice-Hall. Becker, M. (1974). The Health Belief Model and Personal
Health Behavior,
Journal of Health Education. 2, 324-348. Benett,P., & Hodgson, R.
(1993). Psychology and Health Promotion,
London: Rontledge. Bunton, R., & Macdonald, G. (1993). Health
Promotio, London: Rontledge. Clark, M. (1992). Emotion and social behavior,
Sage Publ., New Bury Park. Coie, J., Watt, N., & West, S. (1993). The Science
of Prevention. American
Psychologist, 10, 1013-1022. Fontana, D. (1989). Managing Stress,
London: Rontledge. Janis, J. (1977). Decision making: a psychological analysis
of conflict, choice
and commitment, N.Y., Free Press. Kazdin, A. (1993). Adolescent
Mental Health-Prevention and Treatment
Programs, American Psychologist. 2, 127-141. Prochaska, J., &
DiClemente, C. (1984). The Transtheoretical Approach:
Homewood. II: Don Jones/ Irwin. Rakos, R. (1991). Assertive
Behavior: Theory, Research and Training,
London: Rontledge. Rees, J., & Graham. R. (1991). Assertiveness
training, Wiley, Chichester. Rogers, E. (1983). Diffusion ofinovations, N.Y.,
Free Press. Rosenstock, I. (1985). Understanding and enhancing patient
compliance,
Diabetes Care, 8, 610-616. Sims, A., & Snaith, J. (1988). Anxiety in
clinical practice, Wiley, Chichester. Tannabill, A. (1993). Epidemiology
and health promotion, Rontledge,
London. Thyer, B. (1987). Treating anxiety disorders, Sage
Publ., N.Y.
145
Capitolul 9
CONCLUZII t DISCUII
_ pan DAV1D"
talk
M~t "General Disc^ions",In this J
*
*
*
*
*
Chapter 9
m
is
et0
.
'
nshi
damental
research
and
clinical
een
fun
about
the
relati
P
***.
*
ue
more
grounded
on
the
results
practice, arguingthat practice must
praC yCa
of
fundamental research
practice.
Key
" [caldimC
-Cuvinte
cheie:W**+~T*[#
cercetare juna
147
OQ
Capitolul 1
BUTADE UN PSIHOLOG
|
HIPNOZA %GN1TIVIST
. Dan DAVID-
Bolyai, Cluj-W
obiective (^^
de ^ount, ^
hipnozei pnntr-o
programul are .
de cercetare fW
P-is, Pe/ermf anelor nipnote c don^enmd
i definirea 6 la conceptele J m inform|iei; (2) clarii
conexarea ace* ^ paradigma procesam
psihologie, n W
in
n
d
rf^
Procedura de induc ie
Transa
hipnotic
hipnotic
Stare de Fenomene hipnotice
veghe
Sugestii
specifice
Anularea
sugestiilor
specifice
Procedura de
anulare a induc ie
hipnotice
(nivel de adncime)
Ex.: catalepsie,
amnezie
posthipnotic,
hipermnezie
hipnotic,
anestezie i
analgezie
etc.
*
uoar
medie
+
profund
155
154
f
;-m si tts scM - u*^r
oSTnital revoluionar i progresrst, programul rmrat de Barba-w
uei uiiuai
,
j_-xg: dogmatismul teoretico-metodologic
blocat la un moment dat nepu and dqjJ-^ ^^ ^^
al
^v^^ta^P
.^ d nu a penetrat niciodat
teoretrce
^*?**Zfl^
deoarece,
n
numele
unui
pozitivism
serios practica clinica i juridica. Aceasta
,
preferenial
logic tieo^ ridicat de behavioT^taW^egp,
P^ ^
relaia stimul-rspuns sau ^ab%^^\^ a programului) sau studiul hrpnozei,
ignorndu-se (m P&* P fJ) lucrrile minlmal1Zndu-se i f^^^vJ^
informaionale -<** J^^ din psihologia cognitiv,
n studiul hipnozei s-a rupt de cerceta
rigur0ase care i-ar fi dat un
lipsi^wast^deosurs^o^de^o"^
^^
ascendent n lupta cu paradigm ^J^* "Jir* ns hipnoza
XSJSSJSZ
caracterulm
lors^r
(n
lectur,
audiat
muzic
etc.)
Absorbie/Implicare
n imaginar
TRANSAB
Abordarea
social asupra
(dup Fellows,
157
Fenomen
e
hipnotice
Ex.: catalepsie,
amnezie hipnotic,
etc.
Figura 2.
cognitivhipnozei
1986).
modaliti
160
161
- subieci cu imagina ie m;
- studii experimentale
Uf** comPrtamental
Figura 3. Abordare" ^
modern
<BUph
fenomene hipnotice
lc
;ie
hipnotica
iaii etc.
-subiect,cuimadna,-,- -
"
w
ozei.
'""""'""entaj^e
.6 ALE ABORDARn rn
COMPONl^E MODERNE As^ly
COMPORTAM^ 51 PRECIZRI SVPUm^OZF1
(FIG. 3). DETAt^ . , ,. u
^%5
/W^c//e %ww?* care
;
ipiraia subiectului, prPjIi% f
'
Se face
mul extern fex. nurt* <#
P sugestii **._. .
, ct sszfrr*
*
,.
,
/ui'' /iS. owect etc)
;
spiraia subiectului, Pr%jC0 L &
'
aii
Pe
"
^
u
gestii
"^ h,P^te
168
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Baddeley, A. D. (1986). Working Memory, Oxford, Claredon.
Baer, D. (1987). On the relation between fundamental and applied research.
Barber, T. X. (1969). Hypnosis: A Scientific Approach, New-York and
London: Van Nostrand Reinhold.
Barber, T. X. (1979). Suggested Behaviour: the Trance Paradigm versus an
Alternative Paradigm, In E. Fromm & R. E. Shor (Eds.). Hypnosis:
Developments in Research and New Perspectives, New-York,
Aldine. Broadbendt, D. E. (1958). Perception and Communication,
New-York,
Pergamon. David, D. (1997). Hipnoza vzut de un psiholog cognitivist.
Cogniie, Creier,
Comportament, nr. 1 53-67. Edmonston, W. E. (1981). Hypnosis and
Relaxation. Modern Versification of
an Old Equation, New-York, Wiley. Fellows, B. J. (1986). The Concept
of Trance, In Naish, P. L. N. (1986). What
is Hypnosis. Open University Press. Gauld, A. (1992). A History
ofHypnotism, Cambridge, University Press. Gheorghiu, V. A. (1977).
Hipnoza, Editura tiinific i Enciclopedic,
Bucureti.
Gorassini, J., & Spanos, N. P. (1986). A Cognitive Skills Approach to the
Successful Modification of Hypnotic Susceptibility, Journal of
Personality and Social Psychology, 50, 1004-1012.
Hadley, J., & Staudacher, C. (1994). Hypnosis for Change, New Harbinger,
S.U.A. Heap, M. (1988). Born-again Mesmerism ?, The Psychologist
1: 261-2. Heap, M. (1991). Hypnotherapy, Open University Press. Hilgard, E.
R. (1965). Hypnotic Susceptibility, New-York, Harcourt, Broce &
Warld. Hilgard, E. R. (1973). A Neodissociation Interpretation
ofPain Reduction in
Hypnosis, Psychological Review, 80, 396-411. Holdevici, I. (1996).
Elemente de psihoterapie. Editura AII, Bucureti. Jacoby, L. (1991). A Process
Dissociation Framework: Separating Automatic
from Intenional Uses of Memory, Journal of Memory and Language,
30,513-514. Janet, P. (1925). Psychological Healing: A Historical
and Clinical Study,
New-York, Macmillan. Johnson, M. H. (1994). Process of
successful intenional forgetting,
Psychological Bulletin,2,274-292 Kosslyn, M. S.
(1990). Mental Imagery, M.I.T., Cambridge.
169
Chapterll
HYPNOSIS AND OPERAIONAL
READINESS THEORY.
AN INFORMATION PROCESSING
ACCOUNT
-DanDAVIDCapitolul 11 este intitulat "Hipnoza din perspectiva teoriei deschiderii
operaionale: o abordare cognitiv". In acest capitol prezentm teoria
deschiderii operaionale asupra hipnozei i rezultatele experimentale
care o susin, precum i relaia acesteia cu mai clasicele teorii
neodisociaioniste i cognitiv-sociale asupra hipnozei.
Cuvinte cheie: hipnoz, teoria deschiderii operaionale, hipnoterapie.
Keywords: hypnosis, operaional readiness theory, hypnotherapy.
1. INTRODUCTION
170
171
'
2. A BIT OF HISTORY
We will briefly describe the historical development of hypnosis. will
be based on an excellent and comprehensive review of hypnos historical
development (Spanos and Chaves, 1992) published in a classii book "Theories
of Hypnosis. Current Models and Perspectives" edited b Lynn and Rhue
(1992).
An honest review of all psychological healing techniques proves th~
hypnosis has been practiced, even if under many different labels, since t' dawn
of history. Nowadays, hypnosis is a respectable scientifi
psychotherapeutic technique being largely implemented in psychotherapeuti
and residency programs.
2.1. Hypnosis from ancient times to the the mid-1700s
Probably the first hypnotist was Lord God. Genesis 2:21-22 contains
what some people claim is the earliest recorded description of the
hypnoanestesia (Udolf, 1987): "And Lord God caused a deep sleep to fall
upon Adam; and he took one of his ribs, and closed up the flesh instead
thereof; and from the rib, which Lord God had taken from man, made he a
women".
After that "God teaches his sons" the ancient Chinese, Indians,
Persians, Egyptians, Hebrews, Greeks, Romans and others - "specially (even
later) his beloved son Jesus"- to do the same thing. As a consequence, more
than 4.000 years ago Assyro-Babylonian physician-priests and Egyptian
priests used exorcist-hypnotic methods to destroy the demons responsible for
illness.
Others, as the Hebrew, used for the same purpose magical rites
invoking monotheistic God with prayers and mercy. In the Talmud, Kavanah
supposes relaxation and concentration enhanced by accompanying chanting,
breathing exercises, fixation on the letters in the Jewish alphabet that God
spelled etc. All these methods are similar to the practice of Yoga, Taoism (see
early Chinese), Zen, Buddhism, Hinduism, Christian meditation including the
repetitive prayers developed in the Byzantine Church.
The ancients knew the interrelated influence of mind-body, with its
impact on health and illness. Hippocrates noticed that "soul sees quite well the
affections suffered by the body". The legendary Asclepiodes alloyed pain by
the stroking of his hands and the induction of sleep-like states. In other rites,
the Asclepiodes priests introduced patients into the dream-healing rooms.
After interpreting the dreams, they formulated the treatment consisting
172
mainly of vary rites and prayers. The real causes of healing in our dayterms in
all these rites were relaxation, expectancies, imagery, and suggestion;
nowadays we would caii it cognitive-behavioral modifications and placebo
effects.
After the era of demoniacal possession (still alive in some places
even nowadays) a new era began- the era of the magnetism. Starting with the
observations of Petrus Pomponatius (1462-1526) the magnetic theory
assumed that a subtle magnetic influence from the planets and stars affects the
niind and the body. The healing could be achieved by magnets that could
equilibrate the imbalance of the magnetic fluid in our body. The equilibration
was most of the time preceded by a crisis expressed in motor convulsions,
faint, temporal memory loss etc. 2.2. From the mid 1700s to l&h century or
from mesmerism to hypnosis.
The most prominent figure of this period was that of Franz Anton
Mesmer (1734-1815). Mesmer borrowed exorcist-like techniques (e.g. touch
with the hand) from Father Gassner (a classic who was a well-known authority
in exorcism) and incorporated the theory and the practice of magnetism (from
the work of Paracelsus and Mead) elaborating what is called animal magnetism,
a cornerstone for modern psychotherapy. Animal magnetism is a property
of the animal body, which makes it sensitive to universal gravitation as Mesmer
said in his Ph.D. dissertation "De planetarum influxu." Using this theoretical and
technical framework Mesmer achieved huge fame, treating successfully over
15.000 cases. This success decayed when a commission was set up in 1784 by
the Academie des Sciences from France to investigate Mesmer's animal
magnetism cures. The commission was headed by Benjamin Franklin and
consisted of great personalities of that time like Lavoasier, Guillotine, Deslon
etc.
The commission concluded that magnetism without imagination
produced nothing. This statement reduced the influence of the mesmerism in
healing processes and methods. Despite of Deslon's -a member of the
commission- stating: "if the imagination is so effective why do we not use it"
his question has been ignored for 200 years. However, certain Mesmer's
colleagues and followers were still interested in Mesmer's work even if some
of them chose another perspective.
Marquis de Puysequr (1751-1825) is the precursor of modern
hypnosis. Some of his patients exhibited none of the expected convulsion or
other signs of crisis; instead, they appeared to enter a state that resembled
very much to what is called today hypnosis.
173
they are 'n orjvious regress (but see the idea of primary versus secondary
processes in hypnosis, Nash, 1988), their impact on research and practice
being low. Anyway, they could be interesting to be studied from a historical
perspective because of their background in earlier theories of hypnosis (see
Freud's perspective for psychological regression theory and Pavlov's
perspectives for anesis theory).
3.1.1. Neodissociation theory (Hilgard, 1965,1973,1992).
Neodissociation perspective is one of the most dominant
contemporary theories in classical trance paradigm. The neodissociation
theory has its background in the work of Pierre Janet (1925) and his classic
dissociation theory. According to Janet, dissociation is a defensive process in
which memories are split off and kept unintegrated, generating funcional
anomalies of hysteria and hypnosis. Both hysteria and hypnosis involve an
underlying neuropathy. The interaction between psychic trauma and hypnotic
induction procedure on one hand, and neuropathy on the other hand,
generates dissociation that explains both funcional anomalies of hysteria and
hypnosis phenomena.
The use of term "neodissociation theory" has been selected by
Hilgard to indicate that although the historical background is the classical
dissociation theory, the modern theory does not adhere to the same
assumptions as the older theory did, tying dissociation to psycho and
neuropathological conditions.
Neodissociation theory assumes that there are multiple cognitive
systems, each of which has some degree of autonomy, or cognitive structures
in hierarchical arrangement under the control of an "executive ego". The
executive ego plns and monitors the function of all cognitive systems of
personality. Under hypnosis, because of the hypnotic induction procedure, a
disruption of the link between the cognitive system and the executive ego is
produced and the disruption generates dissociative experiences. The hypnotist
influences the hypnotic responses (a cognitive system) by the agency of the
executive ego but an amnesic barrier alters reciprocal awareness between the
executive ego and the cognitive system. The hypnotized subject may be
unaware of the dissociated cognitive system that generates a certain response
or he may be aware of it but perceives the response as being involuntary (see
fig.l).
In short, according to the neodissociation theory, hypnotic responses
occur when the part of the person that responds to suggestions (cognitive
system) is partially split off from the part associated with consciousness
(executive ego). Moreover, an amnesic barrier prevents the executive ego
from gaining direct (verbal) access to the information in the dissociated
cognitive system. Anyway, the executive ego does not transfer all its
177
Constrains on
Ego Autonomy
(Including Hypnosis)
Ego;
Central Control
Structure
l
1
'
^^^^
t.
II
Output
Cognitive Control
Structure 2
| Input
t'
Input
Cognitive Control
Structure
'
Cognitive Control
Structure 3
t-
Ou u
t,
t
Input
t"
Out u
,
t
182
4.2-Jtl
-d
Sdiness- Operaional^ne
.^.^
responses (in case of ac
C
^ an
sVstem to generate .J"
classes of responses, (m ca*
Svated mental >
W1th certam orft If a smn^
mental sets) m he nteraC
^^
p ^^
{]^
Tcuvated mental set the |
^^
is becauSe the actwated rn^nt
voluntary -J^^^-c for stimulus processing
require additional attention
inv0luntary the
^ tnore activat -J^.ft. ^^
generate* respon*^
inhibited
mental et, he gp
^
ultes more
ThlS ,S b
rToctsint-d response generatior, for
stimulus processing
ronstraints on our
Theenvironment
aulomatically imposes co
laborated m
^^ Q
The environment au
mjer
iaught
e*c d^gj^ example, in
lnformation proces ^n^ our is
ontoge
n0t to
our ontogenetic JjJ^l ***
^^C read, wnte, leam etc
what "is permitted to do an
^
^ fl0t
tted to reaa,
aclasstoom^^^^ respoivSes ^jJJ&e the menta
^^
(we have *e mental sets t
(
st rf us
and
permitted" to dnnk ***, *i
^ inVagine we are m
^ and
sets for these.*^S aparagraptah, abook.This* Q
.^ d
the teacher qiuresjMJ read P ^ attntional resource^^ ^ t, t
our response wou ^ ^
because of its acttvated
&
tr
and experienced quxte nv
^ clasawll and, whije
^
a
context. Now iiMf6^ me t0 undress, sit up on.the^
tural. If I
the teacher suddenyg^S and I .Ould fmd this acti song. I would
teei
183
decide to act like this, I will experience it as requiring voluntary effort and
control because of its inhibited mental set in that context.
The executive ego
The importance of planning was brought to attention in a book of
Miller, Galantes and Pribram titled "Plans and the structure of Behavior",
written in 1960. The human being is not only respondent to stimuli but has
plns and intentions understood as a conscious decision to execute a response
in specified environmental circumstances. In modern cognitive psychology,
the nature of the executive ego as a cognitive structure that generates plns
and intentions is understood as interrelated knowledge (or mental sets) about
us and our past, present, and future experiences. The intentions and the plns
generated by the executive ego irapose constraints on our information
processing, generating a certain operaional readiness for acting according to
our intentions. According to Golbruitzer (1993), implementation of intentions
links anticipated situations to intended responses in the sense of "when X
occurs, TU execute Y". This kind of intention has been demonstrated to lead
to the automatic initiation of the intended behavior when the situation
specified in the implementation intention is encountered. The concept is
important here because it allows us to understand that even the initiation of a
novei behavior is associated with involuntary processes and not just the
initiation of a behavior that has been habitualized by frequent and consistent
pairing of a given situation with a specific behavior.
The role ofhypnosis
Generally speaking, hypnosis, more precisely hypnotic induction
procedures reduce the constraints imposed on our information processing by
environment and executive ego, generating this way a larger operaional
readiness that could sustain a large spectrum of responses.
The reduction of the executive ego constraints
Instead of forming intentions for specific responses, hypnotized
subjects delegate some control of their responses to the hypnotist so that the
executive ego does not impose constraints on their information processing,
generating this way a larger operaional readiness (or in connexionist terms a relaxation of the network). By a larger operaional readiness, I mean that:
1. there aren't many inhibited mental sets so that more behaviors are
possible to be experienced more involuntarily;
2. most of the mental sets are deactivated or have a rest of activation;
3. there are a few activated mental sets that correspond to the subject's
expectancies about what is going to happen under hypnosis. Anyway,
being infrequent mental sets (e.g. hand lifting), they aren't generally
184
connected with other mental sets by an inhibitive or excitative link but mainly
a neutral one so that they do not interfere with the functioning of
the other mental sets.
When a stimulus (e.g. a suggestion) fits this kind of mental set (activated or
deactivated but not inhibited) in a relaxed network, few repetitions of a stimulus
will be enough to activate the mental set in order to generate a certain response. It
isn't necessary to allocate many attentional resources to activate the mental set
because there isn't a strong inhibition of the other mental sets, deactivated
themselves. More than that, in hypnosis various instructions often precede the
suggestions. The instructions could manipulate the operaional readiness so that
the mental set of the next suggested response is activated and the suggested
response will be experienced involuntarily. For example, before we suggest to our
subject that he can hear the sounds of the waves he may be introduced to imagine
himself near the sea, lying on the warm sand, he can see the blue color of the sky
etc. This instruction will activate the knowledge about the sounds of the waves.
After this mental set is activated, the suggestion that he hears the sounds of the
waves could be very real even if the subject is in the classroom, 200 miles from
the sea.
In the reduction of the executive ego constraints, very important roles
have (1) the positive attitudes of the subjects toward hypnotist and hypnosis
and also toward being hypnotized; (2) a high motivation to be hypnotized. If
these two conditions are met, then the subject will give up forming intentions
himself, delegating some control of his responses to the hypnotist.
The reduction of the environmental constraints
The reduction of the environmental constraints has the same effect as the
reduction of the executive ego-constraints: a larger operaional readiness. The
reduction of the environmental constraints could affect operaional readiness
directly or indirectly (by influencing the activity of the executive ego, in fact,
reducing the executive ego constraints -see for example the phenomenon of
depersonalization in subjects isolated from environment). So that a larger
operaional readiness could be achieved by reducing the environmental
constraints. Hypnotic induction procedure has this mission. It is realized by:
1. making hypnosis in a quiet place (no many environment stimulation);
2. asking the subject to find a comfortable position (no many
proprioceptive stimulation);
3. asking the subject to close his eyes (no many environmental
stimulation);
4. teaching the subject not to attend to environmental stimuli by using his
inhibitory resources, but to focus his attentional resources on certain
internai or externai stimulus (it will generate no many information
processing of the environment stimuli and stimulating the habituation);
185
or
,,ng sleep, relaxation or alertness Suggestions (it will generate no /jflg
OI tne environment, but of a quite ]imited class of stirrluli that
and s ecific effect on
JP.
P
Ur mental sets-there is a neutral
t,
P (ton with most of our mental sets).
4.3. ypnosis is a technique in which ^ hypnotjc (sdf) induction ane creates a large
operaional rea<iiriess reducing the constraints of r^J/TtJZ executive ^ on
<% information processing. Then, K? ; or, , and repeat6d SU8&stions,
involuntary subjective, the ^ehavioral and psychological modlflcations are generated.
Hypnotic
,L/ reteXPerie"ced as involuntary
various instructions
repeatCdbecause>
su by
Tefjf
rL?
S8estions upon a large operational esp
. one actovates a certainattentional
mentalresour
setthat wi subsequently generate
^J^llT"*
^s) in conjunction with specific read V f
an invol
10re Hntary
a n thatresponse.
the aCtivated
S
nrd a n(se ^^
'- ^ .^act rf **
*to interpret the ambiguous sugg* ********
Wlth their pattern
expectfflcies
hJ/fTlS"? deteCtin theory-N^h, 1986). If we have activated a on iJl 1L
" thC hyPntiSt Says -y arm is lightly goingup-1 iCl 3nd h WlH g UP" ** *
ambiguous stimulus inhand 3WTSS movements) could be interprefed as a
P
sensatlori of wdlt^nd elevation of the hand. So th at the a ivated mental sets,0r in
S
60 110165 arC the fond
h// T. in !"
'
^ental factor explaining the core ZTi,
IZ UntarmCSS f hyPnoc phenomena Other factors TJf- hP L r imaination
etc
.) could probably only modulate JlfelctaSe1 ^^ ^ 1CSSPrbab1^ to produce
hypnotic responses
L:r f|,ei ry___ f;. ^1
fundamental assum
wii"' ? 1
Ption of Kirsch and Lynn (1997)
e ex
Vfft
Pectancy
theory but hf
new ideas thatcould
56 11 ThCSe
deVel
soc/? ^ t? ^ P^ents concern: J _e
O1 reduction of the environmental
constraints;
1 ?? is ly? f *e mechanis^ responsible for the activafon of
/1H LVI"" YSiSneglCCted m Wh and Lynn's theory, beyond
S C nCept f general
m n rie *nCeptS
"
*ed and specific implementation
KledW
? etc ); of Peratlnal readiness, various instructions y^jeated
suggestlons
n0t nly
yCZlZ^T* "* ^rpreted as voluntary but in fact,
ntary bCCaUSethe
fJncctt "eqUire
mental sets are mhtb.tedand in
a ir
^words,
words behav
hPh rs many
uenti
al
resources to be performed. In JV
can
be
g,nerated
10
both voluntarily and
</
186
forf^e
*'
hypnosis at a m
a larg
.. ,
5. making sleep, relaxation or alertness suggestions (it will generate no
processing of the environment, but of a quite limited class of stimuli that
have no clear and specific effect on our mental sets-there is a neutral
connection with most of our mental sets).
we
will
experience
voluntariness or
, implicat10"-1" J ---------
,i
meMa, sets
lso
the
r W)
^
c
h
se,s generai nypnohc phenomena
induction procedure or om v
operaional readine-(Da ^996^
^^
by
c activating menta ^e
desired mental set), repeated
certain "^J^toE implemented intentions (e g. under
P
formalized "when X
suggestions or by prevrou y
h^^atncn^I^r*^a large operational
occurs, m ^^^i^^Zi^r^^J^
Sr-^r^U resources to activate the mental set
(David, 1996).
c fficient as hypnosis in generating hypnotic
3. i the motivationaUaskf<*Z^ one can %***
phenomena? It could be it by m
lts (Davld, Musca
necessary fac)rs of hypnosjs^'
^
only
in the case of
P
and Vanga, in press) -gjjg bec^ only they could reduce *e
subjectswithhighim^^J^ ^ ^ hypnotlc mduction
environmental constrai
suggested imagines.
.
procedure)bybecomingab,orbedb^ ^.^ ^
and
2. Is fl^5*35S the factors and *% S p^ena described in operattonal
readiness theory
187
5. GENERAL DISCUSSIONS
Kuhn (1976) insisted the real work of science begin once a
community of scientists nas adopted a paradigm. Researchers in the field of
hypnosis still disagree about which paradigm to adopt, which theory provides
the most accurate, consistent and productive explanation of the hypnotic
phenomena mechanism.
This article was conceived primarily to present a theory of hypnosis,
theory built upon the fundamental assumptions and fundamental research of
experimental cognitive psychology. Our operaional readiness theory assumes
that hypnosis is a technique in which by hypnotic induction procedure one
creates a large operaional readiness, reducing the constraints of the
environment and the executive ego on our information processing. Then, by
various instructions like repeated suggestions one activates certain mental sets
that will subsequently generate, in conjunction with a specific suggestion, an
involuntary response at subjective, cognitive, behavioral and physiological
level.
So far, some of the fundamental assumptions of the operaional
readiness theory have received good experimental support but a lot of work
189
must be done in the future for a more detailed analysis of the theory and its
predictions.
SELECTIVE REFERENCES/BIBLIOGRAFIE
SELECTIV
Barber, T. X. (1969). Hypnosis: A Scientific Approach, New-York and
London: Van Nostrand Reinhold. Barber, T. X. (1979). Suggested
Behaviour: the Trance Paradigm versus an
Alternative Paradigm, In E. Fromm & R. E. Shor (Eds.). Hypnosis:
Developements in Research and New Perspectives, New-York,
Aldine. Bowers, K. S. (1994). On being unconsciously influenced
and informed. In K.
S. Bowers & D. Meichenbaum (Eds.). The unconscious
reconsidered. New York: Wiley. David, D. (1996). Hypnosis. An
information processing account, Paper
presented to Romanian Academy Conference. David, D. (1997).
Hypnosis as the cognitive psychologist view it, Cognition,
Brain and Behavior, no. 1, 45-67. David, D., Musca, N., &
Vanga, A. (in press). Imagination and
involuntariness of hypnotic behavior. Fellows, B. J. (1986). The
Concept ofTrance, In Naish, P.L.N. (1986). What
is Hypnosis. Open University Press. Gorassini, J., & Spanos, N. P.
(1986). A Cognitive Skills Approach to the
Successful Modification of Hypnotic Susceptibility, Journal of
Personality and Social Psychology, 50, 1004-1012. Hilgard, E. R.
(1965). Hypnotic Susceptibility, New-York, Harcourt, Broce &
Warld. Hilgard, E. R. (1973). A Neodissociation Interpretation
ofPain Reduction in
Hypnosis, Psychological Review, 80, 396-411. Hilgard, E. R.
(1992). The Neodissociation Perspective: Hypnosis as
Dissociation, In. In Lynn, S. J. & Rhue, W. J. (1992). Theories of
Hypnosis. Current Models and Perspectives,The Guilford Press. Janet,
P. (1925). Psychological Healing: A Historical and Clinical Study,
New-York, Macmellan. King, J. B., & Council, R. J. (in press).
lntentionality during hypnosis: An
ironic Process Analysis. Kuhn, Th. (1976). The Structure of Scientific
Revolution, Bucureti. Lynn, S. J., & Kirsch, I. (1997J. Hypnotic
Involuntariness and the Automaticityof Everyday Life, American
Journal of Clinical Hypnosis, 40:1, July.
190
Lynn, S. J., & Rhue, W. J. (1992). Theories of Hypnosis. Current Models and
Perspectives, The Guilford Press. pielea, M. (1994). Cognitive
Psychology. Dacia Press, Cluj-Napoca. Nash, M. (1988). Hypnosis: a window
on regression, Bull. Menn. Clin.,
52:383-403. Naish, P. (1986). What is hypnosisl. Academic press,
Oxford. Socolov, P. (1953) in Miclea, M. (1994). Cognitive Psychology.
Gloria Press. Spanos, N. P. (1971). Goal Directed Fantasy and the
Performance of
Hypnotic Test Suggestions, Psychiatry, 34, 86-96. Spanos, N. P., &
Chaves, P. (1992). Views of Hypnosis in History. In Lynn, S.
J. & Rhue, W. J. (1992). Theories of Hypnosis. Current Models and
Perspectives, The Guilford Press. Udolf, R. (1987). Handbook of
Hypnosis for Professionals, Van Nostrand.
191
ETAPELE HIPNOTERPIEI
Capitolul 12
HIPNOTERAPIA
- Irina HOLDEVICI Chapter 12 entitled "Hypnotherapy" presents the general principles of
hypnotherapeutic intervention in clinical practice aho insisting on
detailed description of humanistic-experiential, analytical-dynamic
and ericksonian hypnotic techniques, frequently used in clinical
intervention.
t
Key words: hypnotherapy, dynamic-psychoanalytical, humanisticexperiential and ericksonian hypnotherapy.
Cuvinte cheie: hipnoterapie, hipnoterapie umanist-experienial,
psihanalitic-dinamic i ericksonian.
deschii. Ochii au tendina s se nchid. Clipeti, clipeti tot mai des, pentru ca
nu mai
Poi ine ochii deschii. Clipeti tot mai des i n curnd nu vei mai
Putea ine ochii deschii pentru c pleoapele devin grele, foarte grele ca de
Plumb. Devii tot mai toropit, tot mai relaxat. Pleoapele sunt att de grele
meat, n curnd nu vei mai putea deschide ochii. Pleoapele, devin tot mai
grele i mai strns lipite. (Dac subiectul nu nchide ochii n mod spontan, i se
spune pe un ton ferm: Acum nchide ochii i fii atent n continuare la ceea ce
'i voi spune):
"Ochii sunt nchii acum i te vei relaxa tot mai profund, tot mai
Profund, vei fi tot mai relaxat, tot mai toropit, mai relaxat, tot mai toropit. Vei
atent numai la vocea mea. i vei reveni din stare numai atunci cnd i voi
spune eu s revii. Te vei simi foarte linitit i relaxat. Nimic nu te va tulbura. e
ve
i relaxa profund, foarte profund. Dac se va ntmpla ceva care te poate Pune
n pericol, te vei trezi imediat i vei face fa cu bine situaiei. Te
relaxezi adnc, profund, foarte profund".
Prezentm n cele ce urmeaz i alte cteva tehnici de inducie
hipnotic (Hartland, 1971):
2. Metod rapid de inducie
Subiectul st n picioare n faa terapeutului. Acesta plaseaz minile
Pe umerii subiectului i fixeaz cu privirea rdcina nasului subiectului. I se
s
Pune acestuia:
"Uit-te n ochii mei i imagineaz-i c vei adormi. Vei adormi
repede. Imediat vei intra ntr-un somn profund, adnc, odihnitor. Continu s te
uii n ochii mei. Pe msur ce te uii n ochii mei simi o greutate care
cuprinde tot corpul. Corpul devine tot mai greu. Picioarele sunt grele, foarte
grele. Braele sunt grele, foarte grele. Corpul este greu, tot mai greu, greu ca
de plumb. Pleoapele devin grele, tot mai grele. Te cuprinde o stare de
toropeal, somnolen. Te simi obosit, corpul este att de greu, greu ca
Plumbul. Simi nevoia s dormi. Pleoapele sunt att de grele nct nu poi ine
ochii deschii. Ochii se nchid. Nu poi s-i mai ii deschii. Adormi! Adormi!
Ochii se nchid, se nchid. Dormi! Somn profund!
In utilizarea acestor tehnici trebuie s inem seama de cteva
recomandri:
dac nu este necesar o stare de trans profund, o metod de
inducie rapid este adesea suficient. Dac avem nevoie de o trans mai
profund, atunci utilizm o metod mai lung, cu mai multe detalii;
metodele rapide fac impresie mai puternic asupra spectatorilor;
uneori putem eua s inducem hipnoza cu o metod, dar putem
reui cu alta. De regul, cu metodele mai lungi se reuete mai bine;
pentru scopuri terapeutice metodele mai lungi sunt mai bune pentru
c permit s obinem un control mai bun asupra subiectului.
196
C. Adncirea transei
De regul, dup ce a realizat inducia, terapeutul se va strdui s
obin o mai mare profunzime a strii hipnotice pe care o atinge subiectul su.
pei nu totdeauna o trans profund este necesar pentru atingerea unor
obiective terapeutice, totui pentru explorarea unor conflicte din sfera
personalitii subiectului este de dorit s se obin o trans mai adnc. Pentru
adncirea transei se procedeaz astfel (Hartland, 1971):
"Eti profund relaxat, dar poi intra ntr-o stare de relaxare i mai adnc
dect cea n care te afli acum. Doreti foarte mult s atingi o stare de relaxare ct
mai profund, pentru c aceasta este o experien agreabil, care i va aduce mult
bine. Te vei relaxa tot mai profund i toate sugestiile pe care i le voi da vor fi
foarte eficiente. Eu voi numra acum pn la 5 (se poate numra pn la 10, 20
etc.) i pe msur ce numr, te vei cufunda ntr-o stare de relaxare tot mai
profund, mai adnc, mai plcut. Cnd voi ajunge cu numrtoarea pn la 5
vei fi profund relaxat, toropit, att de toropit, c atunci cnd i voi spune s revii
nu-i vei mai aminti nimic din cele spuse sau fcute n timpul hipnozei. Acum
ncep s numr: 1 - relaxarea (toropeala) devine tot mai profund, din ce n ce
mai profund; 2 - relaxarea devine i mai profund i mai adnc, cu fiecare
cuvnt spus de mine, cu fiecare expiraie, te relaxezi tot mai mult, din ce n ce
mai mult; 3 - relaxarea (toropeala) adnc, vocea mea te relaxeaz tot mai mult,
tot mai mult, din ce n ce mai mult. Te cufunzi ntr-o stare de relaxare foarte
adnc, foarte profund, auzi doar vocea mea care parc vine de undeva de
departe; 4 - continu s te relaxezi tot mai profund pe msur ce numr. Toate
sugestiile pe care i le dau sau i le voi da n viitor vor fi eficiente i n avantajul
sntii tale. Vei ndeplini tot ceea ce i spun s ndeplineti. Nu te teme de
hipnoz pentru c i va face numai bine. Eti convins c nu i se poate ntmpla
nimic ru. Vei rspunde tot mai bine la sugestiile mele. Chiar dac i vorbesc,
eti tot mai relaxat, tot mai profund relaxat. Ori de cte ori i voi spune s auzi,
s vezi sau s simi ceva, vei tri experiene vii ca i cum ar fi n realitate. Vei
auzi, vei vedea i vei simi ca n realitate. Ori de cte ori i voi spune s simi sau
s faci ceva, vei ndeplini imediat cele cerute, pentru c sunt n avantajul tu. Eu
voi putea s nltur sau s modific orice comand pe care i-o dau. Continu s te
retaxezi. Cnd voi ajunge eu numrtoarea la 5 vei fi foarte, foarte profund
relaxat, adnc relaxat i toropit; 5 - profund relaxat, adnc relaxat. Nu vei reveni
din relaxare dect atunci cnd i voi spune s revii sau dac mi se ntmpl mie
ceva, sau dac ceva te amenin. Altfel vei rmne foarte relaxat, adnc relaxat i
vei face tot ceea ce i voi spune eu s faci. Cnd i voi spune s revii nu i vei
mai aminti de nimic, dect de faptul c te-ai relaxat i te-ai
odihnit".
Odat ajuns aici, hipnotizatorul va ncepe s administreze sugestiile
terapeutice specifice pentru care a fost indus hipnoza.
197
ntmplat.
onflictelor
Asociaiile libere
Tehnica este asemntoare cu cea a psihanalizei clasice, diferena
constnd n aceea c n hipnoanaliz demersul are loc n transa hipnotic, iar
procesul asociativ apare mai frecvent sub forma imaginrii. Pacientul e
ncurajat s ia act de diversele imagini, gnduri, asociaii care i trec prin
minte, indiferent dac legturile dintre ele i se par logice sau nu.
nsi inducia hipnotic va nltura unele rezistene la asociaia
liber. Asociaiile se desfoar mai uor n hipnoz i adesea o singur
edin va furniza mai multe informaii relevante dect cteva edine n stare
de veghe. Transa medie este de regul suficient pentru ca pacientul s
produc un material semnificativ pentru psihoterapeut. Hipnoanalistul trebuie
s asculte n mod pasiv i s evite ntreruperea fluxului normal al asociaiilor
pacientului (care vorbete liber) notnd ce i cum se exprim acesta. Dac el
remarc ceva deosebit, trebuie s-1 interogheze pe pacient n legtur cu
problema neclar, direcionnd fluxul asociaiilor acestuia pe canalul dorit.
Dac pacientul se blocheaz, terapeutul pune mna pe fruntea acestuia i
comand: "Voi numra pn la 5 i cnd voi ajunge cu numrtoarea pn la
5, i va veni n minte cuvntul sau imaginea care are legtur cu ceea ce ai
spus nainte" (Hartland, 1978).
Analiza viselor
Dup cum am mai artat, Freud (1953) a denumit visele nocturne
"calea regal spre subcontient". Din punct de vedere psihanalitic visul este
considerat ca o ncercare a ego-ului de rezolvare a problemelor incontiente
ale subiectului. French i Fromm (1964) au artat c visul este o reacie la un
conflict ct i o expresie a unui conflict de natur subcontient. Orice vis nu
este altceva dect o ncercare mai mult sau mai puin izbutit de a rezolva
conflictul. Psihanalistul sau hipnoanalistul care ncearc s descifreze un vis
se afl n situaia unui cercettor care ncearc s descifreze un text scris cu
hieroglife. Acest mesaj trebuie tradus n codul specific strii contiente (de
veghe). Demersul terapeutului trebuie s aib n vedere decodificarea
simbolurilor pentru a le face accesibile mentalului contient al pacientului. In
ceea ce privete interpretarea viselor, hipnoanalistul are un mare avantaj fa
de specialistul n psihanaliz clasic. Psihanalistul trebuie s atepte uneori
sptmni ntregi pentru ca pacientul s relateze visele sale. n acelai timp,
psihanalistul clasic este confruntat mereu cu problema c marea majoritate'a
coninutului viselor - chiar i a celor pe care pacientul i le amintete - a fost
refulat, uitat, reprimat. n schimb, hipnoza pune la dispoziie o serie de
mijloace care faciliteaz i optimizeaz lucrul asupra viselor. Astfel:
Hipnoanalistul are posibilitatea s induc visele n timpul edinei de
hipnoz. Aceste vise pot fi relatata imediat de ctre pacient.
202
HIPNOTERAPII MODERNE
Hipnoza n psihoterapia lui Milton Erickson
Milton Erickson, unul din cei mai talentai psihoterapeui ai ultimei
jumti de secol, are o viziune nou asupra hipnozei. n loc s utilizeze
relaxarea i sugestiile directe aa cum s-a procedat mai bine de 100 de ani, el
propune un nou demers, bazat pe principiul utilizrii i pe sugestii indirecte.
Acest autor spunea adesea c trebuie s spulberm mitul conform cruia unii
oameni nu pot fi hipnotizai.
Autorul era de prere c hipnoza i hipnotismul sunt termeni care se
aplic unui comportament neobinuit, dar normal, care poate fi inclus oricrei
persoane normale, dac sunt ndeplinite anumite condiii, ct i persoanelor
care sufer de diferite tipuri de tulburri. Oamenii normali pot fi hipnotizai n
proporie de 100%. Bolnavii psihici pot fi i ei hipnotizai, dar mai greu. De
asemenea, deficienii mintal pot fi cu greu hipnotizai, iar unii nevrotici se
dovedesc a fi subieci mai dificili (dup Lankton i Lankton, 1983).
Deoarece hipnoza reprezint o modalitate de comunicare i de
identificare a concentrrii interne, putem spune c orice subiect care este
socializat poate fi hipnotizat. Erickson sublinia i faptul c hipnoza reprezint
o form special de relaie interpersonal. El arta c pentru inducerea transei
este necesar o anumit cooperare din partea subiectului, dei uneori aceast
cooperare se poate ascunde n spatele unei atitudini superficiale de respingere
a hipnozei. Din acest motiv, afirmm c oamenii nu pot fi hipnotizai
mpotriva voinei lor.
Erickson este partizanul induciei indirecte: atenia subiectului este
captat prin intermediul instruciunilor paradoxale i metaforelor i prin
utilizarea comportamentului actual. Mecanismul transei presupune realizarea
disocierii dintre instanele contiente i cele incontiente. Erickson este de
prere c hipnoza nu are efecte nocive: "nici un hipnotizator experimentat nu
a postulat existena unor efecte secundare nocive" (cf. Lankton i Lankton,
1983, p. 132).
Cu toate acestea, el a fost contient de faptul c unele aspecte ale
personalitii hipnotizatorului pot declana la subiect un comportament de tip
isteric. Aceste efecte in ns de personalitatea hipnotizatorului, nu de
procesul hipnozei.
Caracteristicile hipnozei ericksoniene
1. Hipnotizatorul trebuie s manifeste ncredere deplin n ceea ce
face, iar aciunile sale trebuie s aib un caracter congruent.
205
1. Poi s
stai linitit
i s
nchizi
ochii?
2. N-ai dori s te concentrezi asupra relaxrii
sau poate ai dori s asculi vocea mea?
3. Vei observa c dac doreti s te miti,
poi s-o faci, dar o vei face foarte greu.
Se poate constata faptul c instruciunile din coloana stng invit
subiectul la rezisten, orict de cooperant ar fi acesta. Cellalt tip de comenzi
este permisiv i reduce rezistenele. De asemenea, Erickson era atent s
aleag astfel cuvintele nct ele s exprime o gndire pozitiv i s stimuleze
inteligena clientului su.
El avea grij s nu ofenseze clientul, excepie fcnd acele situaii
rare n care o ofens era utilizat ca o intervenie terapeutic menit s
ocheze subiectul.
Trebuie evitai termenii care fixeaz atenia clientului asupra unor
aspecte negative, cum ar fi: rezisten, blocaj, impas etc.
3. Disocierea contient - incontient
Metoda de inducie a lui Erickson presupune modaliti diferite de
adresare pentru planul contient i pentru cel incontient, autorul punnd la
baza proceselor de natur incontient activitatea emisferei cerebrale drepte.
Emisfera stng
Emisfera dreapt (Trans)
(Stare de veghe)
Pantomimic Nivel kinestezic Nivel
Nivel lingvistic Nivel muzical Nivel vizuospaial Nivel intuitiv
logic-gramatical
Nivel perceptiv-sintetic Activitate spontan
Nivel raional Nivel
Erickson utilizeaz anecdote i sugestii
abstract Nivel
indirecte pentru a face pe clieni s se comute de
direct Focalizarea
la modelul lor dominant de procesare bazat pe
ateniei Efort
activitatea emisferei cerebrale stngi.
voluntar
Erickson spunea, adesea referitor la
mecanismele incontiente: "Noi tim mai mult dect credem c tim".
Inducia
Inducia cuprinde urmtorii pai:
1) Orientarea clientului n direcia transei.
206
transei.
Orientarea psihologic implic, de regul, doar interogarea clientului
dac a mai fost sau nu n trans vreodat i cum a trit transa respectiv.
Discuia se va centra n jurul transei trecute, pe baza creia se va putea
construi noua trans. n cursul procesului rememorrii vechii stri,
mecanismele psihologice implicate vor fi activate. Hipnoterapeutul va
remarca posibila relaxare muscular, clipitul i chiar micromicri de levitaie
a braului sau degetului, micri pe care le poate amplifica, ncurajnd
intrarea n trans.
Chiar n cazul n care clientul afirm c nu a fost niciodat n trans,
acesta poate fi interogat la ce anume se ateapt. Clienilor de acest tip li se
pot descrie unele experiene familiare care seamn cu transa, cum ar fi de
pild lectura unui roman pasionant care face ca subiectul s se detaeze de
ceea ce este n jur.
Este indicat s se nceap transa cu o discuie n legtur cu
credinele clientului cu privire la ceea ce este hipnoza. Astfel, hipnoterapeutul
i va da seama despre prejudecile i credinele negative pe care le are
clientul cu privire la hipnoz.
Informaiile greite creeaz anxietate, disconfort i, adesea, tind s
slbeasc relaia terapeutic.
Trebuiesc nlturate mai ales urmtoarele prejudeci cu privire la
hipnoz:
1. Hipnoza este o stare stuporoas n care clientul i pierde
autocontrolul.
2. Subiectul va fi extrem de vulnerabil i va face ceea ce nu dorete
s fac.
3. Subiectul nu se va mai trezi din trans.
4. Dac transa este ncununat de succes, subiecii se vor comporta
ca nite roboi.
5. Hipnoza este lucrarea diavolului.
6. Subiecii se pot ndoi de realitatea transei pentru c au rmas
contieni de ceea ce se petrece n jur.
Prejudecata (5) este cel mai dificil de nlturat tocmai pentru c este
cea mai iraional!
207
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-Contient tau
veghe
dreapta sau la stnga, dup limbajul corpului tu. Eu voi tii aceste lucruri
chiar nainte ca tu s-i dai seama de ele.
Mentalul tu incontient tie mult mai mult dect tii tu. Mentalul tu
contient i d seama i este orientat n raport cu situaia de moment. n felul
acesta, i dai seama de birou, de bibliotec, de locul telefonului i de alte
lucruri care nu au nici o legtur cu venirea ta la cabinet. Dar mentalul tu
incontient ignor toate aceste elemente nesemnificative i acord atenie doar
vorbelor mele i propriilor sale reacii.
Majoritatea gndurilor care se petrec n mentalul nostru incontient
au loc fr tirea noastr. Viteza gndului este la fel cu viteza electricitii.
Exist bilioane de celule nervoase care sunt permanent n aciune i tu ai timp
s devii contient doar de o mic parte dintre procese care se desfoar n
creierul tu. Un simplu stimul poate extrage din incontientul tu o
multitudine de gnduri care aparent nu sunt legate ntre ele...
Aa cum am mai subliniat, Erickson face distincia ntre inducerea
hipnotic n stil clasic, care este ritualist i repetitiv, aceeai tehnic fiind
aplicat oricrui pacient i inducia natural, n cadrul creia sunt utilizate
trsturile personalitii pacientului i comportamentul acestuia pentru a
facilita intrarea n trans.
n abordarea bazat pe utilizare, atenia pacientului se fixeaz asupra
unor aspecte ale comportamentului sau personalitii sale n vederea obinerii
unei focalizri interioare.
Terapeutul accept comportamentul i sistemul de referin propriu
pacientului (lumea lui subiectiv).
Exemplu: o pacient s-a oferit ca voluntar pentru o demonstraie de
hipnoz. Erickson i-a cerut s se aeze ct mai comod pe scaun. Pacienta a
cerut voie s-i aprind o igar i a nceput s fumeze ntr-un stil meditativ,
urmrind fumul de igar. Terapeutul a nceput inducia de la aceast situaie,
dnd sugestii n legtur cu inspiraia i expiraia, apoi n legtur cu senzaia
de uurin cu care pacienta ducea igara la gur i apoi cobora lent braul
napoi. Pacienta a intrat ntr-o trans uoar nainte de a termina igara. Apoi
s-au administrat sugestii de relaxare, somn i c n timp ce va dormi, ea va
continua s se bucure de senzaia plcut pe care i-o ofer fumatul.
Sugestiile administrate s-au referit la: plcere, senzaie de uurin,
satisfacie interioar, senzaia de a fi pe deplin absorbit n aciunea de a
fuma, senzaia de confort, fr nevoia de a se preocupa de stimulii externi etc.
Iat deci c terapeutul a utilizat pentru inducia hipnotic
comportamentul de a fuma.
n cadrul altui exemplu, un brbat de 30 de ani a intrat n cabinet i a
nceput s se plimbe ncoace i ncolo afirmnd c el nu poate vorbi despre
problemele sale atunci cnd st jos sau e culcat.
212
213
214
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Gheorghiu, V., & Ciofu, I. (1982). Sugestie i sugestibilitate, Ed. Academiei,
Bucureti. Gheorghiu, V. (1977). Hipnoza, Ed. tiinific, Bucureti.
Hartland, J. (1979). Medical and Dental Hypnosis and its Clinical
Applications, Bailliere Tindall, London. Holdevici, I. (1995).
Autosugestie i relaxare, Ed. Ceres, Bucureti. Holdevici, I. (1995).
Sugestiologie i terapie sugestiv, Ed. Victor, Bucureti. Holdevici, I., &
Vasilescu, I. P. (1991). Hipnoza i forele nelimitate ale
psihismului uman, Ed. Aldomars, Bucureti. Holdevici, I., &
Vasilescu, I. P. (1994). Psihoterapia - Tratament fr
medicamente, Ed. Ceres, Bucureti. Weitzenhoffer, A. M. (1957).
General Techniques of Hypnotism, Grune and
Straton Inc., New York and London.
215
J
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
David, D. (1998). Hypnosis and operaional readiness theory, Studia no. 1-2.
David, D. (1999). Mecanisme incontiente de reactualizare a informaiilor,
Tez de doctorat, Universitatea "Babe-Bolyai", Cluj-Napoca.
Holdevici, I. <1996). Elemente de psihoterapie. Editura AII, Bucureti.
220
Capitolul 14
CONCLUZII SI DISCUII GENERALE
- Dan DAVID Chapter 14 is entitled "General Discussions". In this chapter, we
present the relationship between hypnosis and fundamental research
of cognitive psychology, arguing that hypnosis must be closer related
to it.
Key words: hypnosis, fundamental research.
Cuvinte cheie: hipnoz, cercetare fundamental.
Relund pe scurt cele prezentate pn acum n cadrul programului
cognitivist de studiu al hipnozei i pornind de la aspectele practice ale
hipnozei prezentate n capitolele anterioare putem afirma urmtoarele:
(1). Hipnoza este o tehnic prin care se induc modificri int la
nivelele subiectiv, cognitiv, comportamental i biologic\ fiziologic;
(2). Hipnoza i fenomenele hipnotice trebuie abordate din
perspectiva procesrii informaiei;
(3). Cercetrile viitoare trebuie s se angajeze n elaborarea
microteoriilor despre fenomenele hipnotice int, abandonndu-se abordarea
clasic, holist i globalist. Aceasta va permite eficientizarea hipnozei prin
elaborarea unor noi proceduri care s genereze aplicaii de anvergur n
practica psihologic.
Tehnicile clasice (vezi ca ex. hipnoterapia eriksonian) dovedindu-i
utilitatea clinic trebuie abordate, interpretate i reevaluate din perspectiv
cognitiv, aceasta contribuind la eficientizarea lor i la stimulare progresului
n domeniu.
La nivel teoretic, programul de cercetare prezentat n aceast lucrare
i propune s deschid noi piste de cercetare prin integrarea a dou domenii
relativ distincte de cercetare: hipnoza i psihologia cognitiv. Acest lucru ar
duce la revigorarea, demitizarea i eficientizarea studiului hipnozei printr-o
infuzie de cunotine de vrf din psihologia cognitiv, prefigurndu-se astfel
aplicaii practice de anvergur. Din perspectiva psihologiei cognitive acest
221
demers ar fi un test i o nou dovad a maturitii i rigorii teoreticometodologice la care aceasta a ajuns.
La nivel pragmatic, programul de cercetare vizeaz elaborarea att a
unor tehnici hipnotice noi ct i aprofundarea celor clasice, eficiente n
practica clinic i juridic, precum i construirea unui bogat instrumentar de
diagnoz i modificabilitate a hipnotizabilitii, cu implicaii directe pentru
practica psihologic.
PARTEA A TREIA
(PART THREE)
222
Capitolul 15
EVALUARE DINAMIC I
MODIFICABILITATE COGNITIV
- SZAMOSKOZI tefan In chapter 15 entitled "Dynamic assessment and cognitive
modifiability" we syntheticallypresent thefundamental assumptions of
the dynamic assessment paradigm, its historical development, and its
impact on assessment of cognitive abilities (e.g. in case of intelligence
assessment).
Key words: dynamic assessment, cognitive modifiability, intelligence. Cuvinte
cheie: evaluare dinamic, modificabilitate cognitiv, inteligen.
Termenii de evaluare dinamic i de modificabilitate cognitiv se
refer la dou domenii de aplicare distincte. Evaluarea dinamic apare ca o
alternativ la instrumentele tradiionale de diagnostic al inteligenei iar
educaia (modificabilitatea) cognitiv desemneaz un ansamblu de metode i
de programe de intervenie cognitiv-comportamental care vizeaz n
principal ameliorarea eficienei intelectuale. Cu toate c sunt dou domenii cu
totul distincte ale psihologiei aplicate, ele au totui o origine teoretic comun
care pornete de la postularea educabilitii inteligenei. n practic cele dou
orientri sunt considerate complementare; educaia cognitiv este privit ca o
prelungire pe terenul educativ a evalurii dinamice a potenialului intelectual
i de dezvoltare.
nc de la nceputul secolului cercetarea inteligenei ca aptitudine
uman general s-a desfurat n trei direcii eseniale: 1. educarea
intelectual a copiilor cu debilitate mintal; 2. analiza experimental a
proceselor cognitive care intr n structura inteligenei; 3. msurarea i
diagnosticul inteligenei. O vreme ndelungat aceste orientri s-au desfurat
relativ independent. Evaluarea dinamic, respectiv educaia cognitiv
reprezint o ncercare de integrare a acestor direcii.
n ncercarea lor de a dezvolta aptitudinile intelectuale ale copiilor
debili mintali, pionierii educaiei speciale au efectuat de fapt primele cercetri
empirice asupra inteligenei i a educabilitii acesteia. Binet de exemplu,
225
229
230
231
234
prstein R
FeU
The
rr^^ Corporation.
Nagiien,Psychological
237
Capitolul 16
NVAREA MEDIAT
-'Anca DOMUA Chapter 16 entitled "Mediated learning experience" (MLE), presents
mediated learning, its mechanisms and its parameters from
Feuerstein's point of view. Intentionality and reciprocity,
transcendence and mediation ofmeaning are necessary conditions for
an interaction to be qualified as MLE; these components of MLE are
considered responsible for what human beings have in common:
structural modiftability.
Key-words: mediated learning experience, structural modifiability,
cognitive development.
Cuvinte cheie: nvare mediat, modifcabilitate cognitiv, dezvoltare
cognitiv.
INTENIONALITATE I RECIPROCITATE.
Intenionalitatea i reciprocitatea sunt caracteristicile definitorii ale
nvrii mediate.
n nvarea mediat, coninutul este modelat de intenia de a media
stimuli, activiti, relaii, acest lucru incluznd i mprtirea inteniei de a
media coninutul respectiv persoanei mediate. Astfel, cel care face medierea
va declara: "te rog s urmreti secvenialitatea acestei proceduri, dac nu
reueti am s o repet", "Te rog s urmreti ceea ce spun, dac nu m-ai auzit
am s vorbesc mai clar", exprimnd astfel intenia de a fi urmrit, i n schimb
239
TRANSCENDENA
MEDIEREA SENSULUI
240
245
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Carew, L. (1980/ Experience and the development of intelligence in young
children at home and in day care, Monographs of the Society for
Research in Child Development, 38. Feuerstein, R., Rnd, Y., &
Hoffman, R. (1980). Instrumental Enrichment:
An Intervention Program. For Cognitive Modifiability. Baltimore:
University Park Press. Hess, R. D., & Shipman, V. C. (1968).
Maternal influences upon early
learning: The cognitive environments of urban pre-school children.
In R. D. Hess and R. M. (Eds.). Early education, current theory,
research and action. Chicago: Aldine. Jensen, M. R., & Feuerstein,
R. (1987). Dynamic assesement of retarded
performers with the Learning Potenial Assessment Device: From
philosophy to practice. In C. S. Lidz (Ed.). Dynamic assessement:
An interactional approach to evaluating learning potenial. NY:
Guilford Press. Klein, P. S. (1992). Assessing cognitive modifiability
oflnfants and Toddlers:
Observations Based on Mediated learning experience. n H. C.
Haywood i E. Tzuriel (Eds.) Interactive Assessment, SpringerVerlag New Zork Berlin Heidelberg. Klein, P. S. (1988). Stability
and change in interaction ofisraeli mothers and
infants. Infant Behavior and Development, 11,55-70.
Capitolul 17
INTELIGEN I TRANSFER
- JANOS Reka In chapter 17, entitled"'Intelligence and transfer", we emphasise and
detail the relationship between intelligence and transfer and its impact
on dynamic assessment and formativ diagnosis.
Key words: intelligence, transfer, dynamic assessment.
Cuvinte cheie: inteligen, transfer, evaluare dinamic.
Diagnosticul formativ (evaluarea dinamic) i transferul nvrii
sunt dou concepte strns legate ntre ele. n cursul unei sesiuni de diagnoz
formativ, examinatorul ofer subiectului cunotine declarative i
procedurale necesare rezolvrii itemilor (faza de nvare), iar ntr-o faz
ulterioar (faza test) se msoar capacitatea subiectului de aplicare, n situaii
noi, a acestor cunotine. Fcnd o retrospectiv asupra studiilor ce au vizat
transferul nvrii, regsim aceast paradigm formativ, ceea ce pledeaz
pentru strnsa relaie ntre evaluarea dinamic i mecanismele transferului.
Pentru o mai bun nelegere a mecanismelor cognitive implicate n
diagnosticul formativ relum mai nti fazele i procesrile cognitive care apar
n cadrul transferului i care par a fi comune n ambele situaii. n majoritatea
experimentelor asupra transferului, ntr-o faz primar, subiecii sunt
confruntai cu o problem (poate fi orice problem de matematic, fizic etc.
sau o prob practic sau motric), care va constitui problema-surs din
experiment. Aceste probleme sunt, n general, astfel alese ca subiecii s nu
aib cunotine anterioare asupra rezolvrii lor. Experimentatorul ofer acele
cunotine care sunt necesare pentru rezolvare i se convinge asupra
performanei de utilizare a acestor cunotine. Subiecii, ntr-o faz secundar,
sunt confruntai cu o alt problem, problema-int, care este similar cu ceea
iniial i se verific performanele subiecilor n rezolvarea ei. Similaritatea
dintre cele dou probleme variaz de la similaritatea total la aceea care se
manifest doar la structura relaional a celor dou probleme. Cu ct sunt mai
similare dou probleme, att la nivelul proprietilor de suprafa ct i la
nivelul structurii relaionale, cu att cresc performanele de rezolvare ale
247
246
250
Cunotine-scop
procedurale
declarative
procedurale
Cunotine de baz
declarative
posibilitate de a trece printr-un obstacol, prin divizarea unei fore mai mari n
uniti mai mici. Or, cnd un subiect reuete abstractizarea acestui principiu,
va fi capabil de rezolvarea unei game largi de probleme care are la baz
tocmai acest principiu.
n cazul probelor formative se ntmpl aceleai lucru: dac subiectul
este capabil s abstractizeze principiile rezolutive, adic procedurile generale,
va fi capabil, dup recunoaterea similaritii, s aplice procedurile n situaii
noi. Dac ns reprezentarea conine principiul de rezolvare legat strns de
contextul n care s-a realizat nvarea, acesta va putea fi aplicat doar la
repetarea itemului. Rolul experimentatorului este:
s stabileasc o conexiune ntre cunotinele acordate de el i
mediul natural al copilului (transfer declarativ-declarativ);
s explice c itemii pot fi conectai pe baza procedurilor de
rezolvare a acestora; deci asimilnd un singur procedeu, acesta poate facilita
rezolvarea mai multor itemi (transfer procedural-procedural).
n multe situaii pot aprea noi cunotine doar pe baza fructificrii
exemplelor modelate n rezolvarea unei probleme ("worked-out examples") n
situaii noi. Din anii '80 att psihologia cognitiv ct i psihologia
educaional prezint un tot mai mare interes asupra acestui tip de nvare,
mai ales n domenii bine structurate (Corral, 1994, Zhu i Simon, 1987).
Cel mai reuit experiment pe aceast tem se leag de numele lui
LeFevre i Dixon (1986), care au studiat strategiile de nvare preferate de
ctre copii. Copiii, n acest experiment, au fost confruntai cu probleme
complexe i li s-a oferit dou soluii de rezolvare ale acestora:
a. O instruciune abstract textual (cunotine declarative);
b. Un exemplu model detaliat (cuprinde secvenial toi paii de
rezolvare) -cunotine procedurale.
Cele dou informaii-surs permiteau delimitarea strict a strategiilor
preferate de copii dup colectarea rezultatelor n rezolvarea problemei.
Rezultatele au artat o preferin clar a exemplelor elaborate i n acele
cazuri n care aceasta conducea la soluii greite sau coninea mult mai puine
informaii dect instruciunea textual.
Preferina pentru exemplele model pare a fi funcional din cel puin
dou considerente (Novick, 1988).
1. Problemele pot fi rezolvate fr deducia greoaie a structurilor
elementare de cunotine. De multe ori, pentru novicii n anumite domenii
tocmai aceast abstractizare a principiilor este imposibil, deoarece nu au
cunotinele declarative necesare.
2. Eficiena modelelor n rezolvarea noilor probleme apare n acele
situaii a cror structur relaional nu este nc cunoscut de copil- In
252
253
254
BIBLIOGRAFIE SELECTIV/SELECTIVE
REFERENCES
Anderson, J. R. (1985). Cognitive Psychology and its implications, New
York: W. H. Freeman & Co. Brooks, L. W., & Dansereau, D. F.
(1987). Transfer of information: An
instructional perspective, In S. P. Cormier & J. D. Hagman (Eds.).
Transfer of learning: Contemporary Research and Applications, New
York: Academic Press. Fong, G. T., & Nisbett, R. E. (1991).
Immediate and delayed transfer of
training effects in statistical reasonig, Journal of Experimental
Psychology: General, 120, 34-45. Gagne, R. M. (1960). The
conditions of learning, New York: Hoit, Rinehart
& Winston. Gick, M. L., & Holyoak, K. J. (1983). Schema induction
and analogical
transfer, Cognitive Psychology, 15, 1-38. Kieras, D. E., & Bovair, S.
(1984). The role of mental model in learning to
operate a device, Cognitive Science, 8, 225-273. LeFevre, J. A., &
Dixon, P. (1986). Do written instructions need examples?
Cognion, 3, 1-30.
255
Chapter 18
DYNAMIC ASSESSMENT OF
HYPNOTIZABILITY
- Dan DA VID -
258
259
moment I will suggest to you that your arm is getting lower and lower" (at the
same time, he moves his arm lower and lower in front of the subject).
In addition, positive attitudes towards hypnosis can be enhanced by
offering the patient a myth about hypnosis containing information about the
history, theories, practice, research, and spectaculous results of hypnosis etc.
Anyway, this myth must be formalized and standardized; future studies must
verify and elaborate an adequate and efficient myth that then can be included
in the D.C.-Carleton package.
*The second component is the same as it is in the Carleton Package.
Anyway, more than that, we try to improve the subject's imaginative ability
by (a) incorporating all his senses: smell, touch, hearing, sights and taste and
(b) specific exercises-see the next exercise.
Exercise:
Fold a sheet ofpaper into halves vertically. In the left column, state
your goals in a positive way, starting from easy goals to difficult goals.
Easy goals:
- imagine a static simple object (a pen)
- imagine a complex static object (video-player)
Goals that are more difficult: - imagine a simple object moving (hali)
- imagine a complex object moving (helicopter)
Difficult goals: - imagine a complex situation
- imagine you are relaxed at work.
In the right column, create a positive image that indicates what you
see, hear.feel.
E.g. for easy goal: I can see a black long pen. Ifeel its surface. for complex
goal: I am sitting at my desk next to the windows. It is a pleasant sunny day. I
am calm and at ease. I hear no sounds and Ifeel warm.
*The third component is the same as it is in the Carleton Package.
Anyway, we do not stimulate so much the subjects' active practice of
behaviors but mainly their active interpretation (attributions) of the causes of
the behavior so that the compliance not to be encouraged.
263
264
Capitolul 19
CONCLUZII I DISCUII GENERALE
- SZAMOSKOZI tefan, Daniel DAVIDHere, in chapter 19, entitled "Conclusions and Discussions", we
make some comments about dynamic assessment arguing that: (1)
dynamic assessment can be seen as a paradigmatic shift in the context
of psychological assessment, stimulated by the development of
cognitive psychology, and (2) the concept must be extended beyond the
classical meaning related to cognitive functions assessment toward
traits assessment (e.g. hypnotizability). Key Words: paradigmatic
shift, dynamic assessment. Cuvinte Cheie: schimbare de paradigm,
evaluare dinamic.
Psihologia cognitiv a trecut de la o abordare structural a
funcionrii cognitive (vezi de exemplu grupul de cuaternalitate a lui Piaget),
la una procesual, concentrndu-se pe naintarea efectiv n rezolvarea
problemei i nu pe produsul procesului rezolutiv.
Pentru o mai bun analiz a funcionrii cognitive, aceasta a fost
descompus n uniti minimale sau mecanisme primitive. O unitate minimal
de prelucrare a informaiei (un "atom de procesare") se numete component.
Analiza componenial permite realizarea unor corespondene relevante ntre
nivelele cognitiv i cel neurochimic de funcionare a sistemului uman.
Aadar, metoda analizei componeniale (Sternberg, 1977) vizeaz
descompunerea factorilor cognitivi n componente primare de procesare a
informaiei. De exemplu, factorul "raionament inductiv" poate fi descompus
n mai multe componente: 1. capacitatea de codare a stimulilor; 2. capacitatea
de a stabili conexiuni, relaii relevante ntre termenii unitilor de informaie;
3. aptitudinea de aplicare a relaiilor stabilite n contexte diferite; 4.
posibilitatea de a compara rezolvrile alternative n termenii similaritndisimlaritii acestora; 5. capacitatea de a combina soluiile virtuale ntr-o
strategie rezolutiv coerent; 6. justificarea validitii unei strategii rezolutive,
7. aplicarea strategiei rezolutive. Aceste componente de procesare a
informaiei pot fi examinate separat, stabilindu-se mult mai precis diferene e
individuale dect pe baza unui IQ global.
265
Capitolul 20
REMARCI GENERALE
- Dan DA VID Chapter 20 is entitled "General Remarks". In this chapter, we
emphasize again the relationship between fundamental research and
clinical intervention, arguing that having effective intervention in
clinical practice and human development it supposes rigorous
fundamental research.
Key words: general remarks on clinical practice.
Cuvinte cheie: remarci generale asupra practicii clinice.
j
266
267
PSH - '