Judith S. Beck, PhD, President, Beck Institute for Cognitive Behavior Therapy

Aaron T. Beck, MD and Paul Grant, PhD developed Recovery-Oriented Cognitive Therapy (CT-R) for individuals diagnosed with serious mental health conditions, such as schizophrenia and bipolar disorder (Grant et al., 2012). Research demonstrates that traditional CBT reduces clients’ symptoms of psychopathology, such as depression and anxiety, but it isn’t as effective in increasing their sense of well-being (Widnall et al., 2020). It is the sense of well-being, comprising recovery, empowerment, and resilience, which is at the heart of CT-R. I have incorporated the principles of CT-R in my work with clients (J. Beck, 2021), enriching my practice and increasing my effectiveness.

Ever since I began to practice CBT, I have helped my clients plan and engage in positive activities, and I praised them or gave them credit for doing so. But just having positive experiences, and even receiving positive reinforcement isn’t enough. What I was missing was helping my clients receive maximum benefit by eliciting positive meanings of these experiences, providing opportunities for them to feel positive emotions in session, and increasing the strength of their positive beliefs.

A routine part of the beginning of my sessions with clients has always been to ask them what happened between our previous session and the current one that is important for me to know. For a long time now, I have also been careful to ask one of the following questions to elicit their positive experiences:

  • When did you feel even a little better this week?
  • What happened that was even a little positive this week?
  • What did you do this week that deserves credit?
  • What did you do this week that you weren’t able to do at the beginning of treatment?

Recently, I started asking one of the below questions:

  • When were you at your best this week?
  • When were you at your best this week in terms of your goal of ______?

I might follow up an initial question with one of these:

  • Isn’t it great that ___________?
  • How was doing ___________ connected to your values or aspirations?
  • What was the best part about __________?

Then, if I think clients will have difficulty drawing a positive conclusion on their own, I’ll offer one and ask them to reflect on it, for example:

  • Did your prediction that you wouldn’t have enough energy come true? What did happen in terms of your energy level?
  • Does this show that you really are competent in paying your bills?  What else did you do this week that showed you were competent?

But if clients can draw a positive conclusion, it’s better to phrase a question in a different way: What does it mean or say that ____________?

  • So, you went out of your way to help that woman in the store? What does that say about you?
  • So, the “old timers” at the meeting seemed happy to show you the ropes? What does that say about at least some other people?
  • So, your boss ended up giving you a really positive evaluation? What does that say about you? What might that mean about your future?

Then you might consider asking your clients:

  • How did it feel as you were doing ______? [or, when you finished doing _____?]
  • Can you imagine the experience as if it’s happening now?
  • Can you get some of that same good feeling you felt at the time?
  • Can you see how just remembering this experience can help your mood?

When I first started working with Chaya,* she was severely depressed and hopeless. She spent a great deal of time when she wasn’t at work lying on her couch and scrolling through videos on her phone. She got little, if any, pleasure from this activity. But she had lots of negative thoughts that interfered with doing other things like calling her sister, getting together with her neighbor, working on a needlepoint project, or playing a video she could exercise to. After we spent part of a session reviewing her values and aspirations and evaluating and responding to some interfering automatic thoughts, she agreed to discuss behavioral activation. We collaboratively devised a set of experiments for her to try after work each day and on the weekend to see what impact these activities had, if any, on her mood.

At our next session, I did a mood check. Then I asked her what had happened during the week that was important for me to know. She told me about a problem she had with a co-worker who had been rude to her and we agreed to put that on the agenda. Then I asked her, “When this week did you feel even a little better?” She acknowledged it was when she talked on the phone with her sister, when she and a neighbor had coffee together, and when she did some needlework. “I’m so glad,” I told her. Then I said, “At our last session, you weren’t sure you’d have the energy to do anything except lie on your couch. What did you find out?” She concluded that she had more energy than she had predicted.

“And you didn’t think your neighbor would want to get together with you because you had turned down a couple of her invitations recently. What happened?” Chaya said that her neighbor hugged her and said she had really missed her. I asked Chaya what that said about her, and she concluded, “I guess she wasn’t mad, that she really does like me.”

At each session, I was careful to spend some time at the beginning of each session to help Chaya derive meanings from the positive experiences she had had during the week. These positive conclusions provided much needed evidence to support her positive beliefs.

Recovery-Oriented Cognitive Therapy isn’t just for individuals diagnosed with serious mental health conditions. It can be incorporated into more traditional CBT. If you try a CT-R intervention yourself, please email me at help@beckinstitute.org and tell me about it.

*Client’s names and identifying details have been changed to protect confidentiality.

References:

Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N. M., & Beck, A. T. (2012). Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of General Psychiatry, 69(2), 121–127. https://doi.org/10.1001/archgenpsychiatry.2011.1546

Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). The Guilford Press.

Widnall, E., Price, A., Trompetter, H., & Dunn, B. D. (2020). Routine cognitive behavioural therapy for anxiety and depression is more effective at repairing symptoms of psychopathology than enhancing wellbeing. Cognitive Therapy and Research, 44(6), 1121-1131. https://doi.org/10.1007/s10608-020-10111-7