Recovery-Oriented Cognitive Therapy (CT-R) is an extension of the important work of CBT for psychosis (CBTp) to individuals who have struggled to gain benefit from that approach. CBTp was originally developed to address positive symptoms (hallucinations and delusions) to help people regain their lives. It uses Aaron T. Beck’s cognitive model. CBTp maintains a strong evidence base and has been adopted in many places throughout the world as a key treatment for individuals with schizophrenia-spectrum diagnoses.
CT-R is formulated for individuals struggling the most with living their desired life. Practitioners sometimes view them as incapable of recovery. These individuals might struggle with:
- problems with motivation and connection,
- constant hallucinations,
- entrenched delusions,
- thought disorder,
- whether they have an illness at all,
- self-injury, and
- reactions to trauma.
These individuals have traditionally been considered unreachable with other psychosocial interventions and might have failed to respond to medications, frustrating their recovery efforts. CT-R uses a specific formulation for the problems of motivation, connection, and expression (negative symptoms) as well as other symptoms.
It employs specific, systematic strategies to overcome these obstacles. In a recent study, individuals with greater negative symptoms at discharge were rehospitalized sooner than individuals with positive symptoms and cognitive deficits (Ahmed et al, 2015).
Aaron Beck focused his attention on the negative symptoms of schizophrenia in collaboration with Paul M. Grant. They propose that negative symptoms have classically been misunderstood as an expression of the cognitive deficits observed in these individuals. Grant and Beck (2009) identified certain beliefs that explained the relationship between deficits and negative symptoms, namely, dysfunctional, defeatist beliefs such as, “It’s not going to work out so there’s no use in trying,” and “If I make a small mistake, it is as bad as a complete catastrophe.”
They targeted these beliefs in a clinical trial. They found that the intervention, which emphasized the modification of these beliefs, had a significant impact on individuals’ functioning, avolition/apathy, and positive symptoms. They also found that these gains were maintained at the six-month follow-up (Grant et al, 2017). Interestingly, positive symptoms, though they were not the direct target of the intervention, decreased. The study found that as individuals’ motivation increased, they did more. (Their functioning improved). As they became more active, they focused less on hallucinations and delusions (which led to less experience of those symptoms), which increased motivation.
This discovery shifted the focus of treatment to increasing motivation for activity, the identification of meaningful aspirations, and activity scheduling. Restructuring beliefs came about through increasing their activity, through experiential learning, and through achieving important aspects of their desired life.
Next in the evolution of CT-R, the team at the University of Pennsylvania started disseminating the tested intervention in Philadelphia, New Jersey, and Georgia. The procedures supervised by Aaron Beck in the clinical trial were turned into a systematic intervention and training program by Aaron P. Brinen. With each case and training cohort, the strategy was refined to systematically bring recovery to every individual. The protocol consisted of the following steps:
1. Engagement and Activating the adaptive mode:
The initial connection between the therapist and the individual activates a network of beliefs that inhibit or neutralize the symptom-related beliefs and increases access to cognitive resources, activating an adaptive mode. This activation can include:
- pleasurable activities: music, videos, walking, eating;
- exciting, motivating topics: cooking, sports, holidays;
- immediate relief of stress: breathing, voice-reduction techniques; and
- aspirations: talking about the future, and their dreams and hopes.
Engaging individuals provides opportunities for them to develop new hypotheses about motivation, success, connection, and distress, which they can then collaboratively test with the therapist. Engagement helps individuals get into an adaptive mode, largely relieved of their symptoms. For example, a young man suffering from a communication disturbance cannot focus his speech and is inundated with hallucinations. His therapist pulls up a video game on her phone and asks him how to play it. He becomes highly focused and starts telling her the strategy for the game, including ways not to waste energy.
With increased access to cognitive resources, individuals can identify aspirations for the future. They get more energy and activation through envisioning the future they desire through vivid imagery. Individuals then start the process of changing broad aspirations to small objectives they can accomplish right away. For example, as the therapist and the individual play the video game, the therapist asks the individual what else he’d like to be doing or getting. He identifies helping his mom because she has a physical illness. They talk about what it would be like to help her and he becomes more focused. Finally, they discuss some of the ways he can start helping her now.
Motivated by their aspirations, individuals start planning to repeat and evaluate activities they had attempted during the engagement process. Individuals are helped to evaluate potential activities and add them to their daily schedule. They may add additional activities that move them toward their aspirations and increase the likelihood of success. Over the course of treatment, the activity is formalized into an activity schedule and the therapist helps the individual identify the benefits of the activity on motivation, distress, mood, and success.
Learning New Lessons
As individuals become successful in overcoming obstacles and taking action toward their objectives, they learn new lessons that strengthen an adaptive set of beliefs, for example, “Always try; sometimes things work out better than you think,” and “The more you do, the better you feel.” The therapist moves from casually noting the new ideas and drawing conclusions to a more formal procedure of hypothesis testing.
As an obstacle impedes any part of the protocol (engagement, aspirations, taking action), therapists adjust their formulations. Together, individuals and therapists develop a strategy to neutralize the obstacle so the individuals can take action toward their aspirations. These obstacles include hallucinations, delusions, communication disturbance, aggression, self-injury, substance misuse, reactions to trauma, and other problems.
Who is it good for?
CT-R is effective across the span of the illness and settings. The treatment and the original clinical trial were conducted in an outpatient setting. We have successfully adapted this treatment to include:
- team-based approaches (Assertive Community Treatment Teams);
- supported housing settings;
- state hospitals (civil and forensic);
- First Episode Psychosis Coordinated Specialty Care teams;
- peer support;
- residential treatment facilities for adults;
- jail diversion teams;
- day treatment programs;
- group formats;
- family integration;
- medication management checks; and
- systems of care.
The treatment has been successfully applied across the course of the illness, including ultra-high risk, first episode, chronic cases, and deficit syndrome.
As we started training and implementing the treatment, we noticed the common elements within the recovery movement. Specifically, we noted how CT-R was a vehicle to actualize the spirit of recovery. As we talked more about recovery and shifted from a problem focus to a recovery focus, we adopted the name Recovery-Oriented Cognitive Therapy.
CT-R does not start with an assertion that the individual’s experiences are a part of an illness, and does not focus on a problem list. Rather, treatment is oriented toward promoting progress toward aspirations. Therefore, individuals who do not believe they have a mental illness or do not want to be controlled by others, are less likely to reject help. Therapists engage with individuals to move them toward their desired life and to tackle obstacles that get in the way.
CT-R provides a framework for promoting continuity of care across treatment settings. CT-R has been recognized by practitioners, administrators, and individuals as a powerful, effective, and collaborative approach to promoting durable recovery.