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Entrevista::Terapia Cognitiva Processual

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Irismar Reis de Oliveira é médico e professor de Psiquiatria do Departamento de Neurociências e Saúde Mental da Universidade Federal da Bahia, Brasil. Ele é o editor de seção de Psicologia Clínica e Psicoterapia para BMC Psicologia. No livro Terapia Cognitiva Processual, o pesquisador apresenta uma nova abordagem técnica, que tem como principal enfoque o registro de pensamentos baseado no processo. Uma estratégia estruturada para mudar crenças nucleares sobre o self, apresentadas como uma analogia centrada na lei, em que o terapeuta coloca o cliente em uma simulação do processo judicial. O livro é um equilíbrio entre teoria, análise científica de um novo método e aplicação da prática.

O senhor trabalha com psiquiatria há 30 anos. Como surgiu o interesse em iniciar a prática em terapia cognitiva? 

Minha prática como terapeuta cognitivo é mais recente, começou há 15 anos. A primeira reação foi a de ter encontrado algo que buscava há muito tempo: a possibilidade de acrescentar algo consistente que pudesse potencializar o tratamento farmacológico, minha única arma e principal competência à época. Ao longo do tempo, entretanto, fui sentindo que havia lacunas nessa nova prática e passei a modificar as técnicas que havia aprendido na Terapia Cognitiva convencional. Ao final de alguns anos, tive a certeza de que algo novo havia sido criado e que era algo de valor. Cheguei a publicar um trabalho em uma revista europeia sobre reversão de sentença, algo que já existia na Terapia Cognitiva e que trazia um sentido positivo às ideias negativas que os pacientes apresentavam. O lado problemático da nova técnica criada era que ela se baseava principalmente na inversão das sentenças, e já questionava diretamente as crenças, à quais os pacientes aderiam fortemente, ainda que elas lhes trouxexssem muito sofrimento. Ter as crenças questionadas antes de uma escuta receptiva e empática não é tomado positivamente pelo paciente, o que lhe dá a impressão de não estar sendo devidamente escutado e compreendido. Convivi com esta dificuldade durante pelo menos um ano após a publicação dessa primeira técnica.

 

Como surgiu a ideia de adaptar o processo de Kafka a sua pratica? 

O interessante é que a resposta a esta pergunta completa a explicação da anterior. Continuei refletindo sobre a dificuldade que citei e, casualmente, em 2007, quando estava passando por uma livraria, encontrei por acaso O Processo, de Kafka, que havia lido na adolescência e que não tinha entendido. Mas reler o livro me fez pensar que, se eu conseguisse transformar essa técnica num processo jurídico, tudo estaria resolvido. Acrescentei duas colunas – aquela em que eu escuto o paciente e ele se queixa à vontade, sem questionamentos, na figura do promotor; a outra coluna seria preenchida pela figura do advogado de defesa como contraposição ao que foi dito pelo promotor. E então nós podemos ter a réplica, a tréplica, os jurados e até testemunhas…  A partir dessa ideia, várias outras técnicas foram acrescentadas e só faltava realizar os trabalhos científicos para testar o que passei a chamar de Terapia Cognitiva Processual ou TCP. A eficácia da TCP, felizmente, vem sendo comprovada inclusive por outros colegas no Brasil e em outros países.

 

Como funciona a abordagem? 

A TCP parece ser mais estruturada e mais experiencial do que a TCC padrão. A principal meta que eu tinha em mente quando desenvolvi a TCP foi torná-la mais fácil para o paciente entendê-la, mas também para o terapeuta compartilhar o modelo cognitivo com o paciente. A TCP tem algumas características que a distinguem do modelo de terapia cognitiva convencional. Por exemplo, nós utilizamos muitas metáforas e a principal delas é a jurídica, como foi citado acima. Minha interpretação do Processo é que Kafka queria propor o princípio universal da autoacusação. Isso é o que equivale ao que se conhece na terapia cognitiva como crença nuclear ou central. Com esse conhecimento, fica mais fácil para o paciente organizar sua própria defesa. Desenvolvi também o diagrama de conceituação da TCP, e outros registros de pensamentos, como o registro de pensamentos intrapessoal e o registro de pensamentos interpessoal. Estes são usados para reestruturar pensamentos automáticos. Nós também desenvolvemos outra técnica conhecida como role-play consensual que, juntamente com a hierarquia dos sintomas baseada nas cores, ajuda o paciente a resolver situações de ambivalência. Mas a técnica mais importante usada na TCP é o próprio Processo, no qual as crenças nucleares são colocadas em julgamento. Outra técnica, denominada “consciência metacognitiva baseada no processo”, ajuda o paciente a se tornar mais consciente de seus pensamentos e crenças e lidar mais adequadamente com eles.

O senhor costuma usar a terapia cognitiva processual para tratar quais tipos de transtornos? 
 
A TCP é uma abordagem transdiagnóstica, significando que ela pode ser usada na maioria dos transtornos psiquiátricos. A razão é que esta abordagem é mais focada na reestruturação das cognições disfuncionais que chamamos de crenças nucleares. E essas crenças negativas disfuncionais se ativam na maioria dos transtornos psiquiátricos.
Como o senhor avalia os resultados deste tipo de terapia? 
Os estudos realizados até o momento mostram algum tipo de benefício. Os dois principais transtornos nos quais a TCP foi testada são a fobia social e o transtorno de estresse pós-traumático, onde se mostrou tão eficaz quanto os tratamentos padrão e até superior em alguns aspectos. Por exemplo, na fobia social, os escores da escala medo de avaliação negativa foram significativamente mais reduzidos do que a TCC padrão.

 

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