The Future of Community Mental Health for Persons with Severe Mental Illness

by Aaron T. Beck, MD

Part 3 of 3

Read part 1, A Biography of Cognitive Behavior Therapy

Read part 2, The Evolution of CBT in Community Mental Health

I think that it is going to take a number of years for us to really get our Recovery Oriented Cognitive Therapy approach fully implanted. The reason is that the approach is novel, and compared to the standard approach for the severely mentally ill, it is revolutionary.  For example, one important principle is that if that you treat these individuals as though they are normal, they are going to react normally.  They are going to show normal affect, normal behavior, and normal thinking.  Our idea is that not only can we bring out the normal personality, but we can maintain the normal personality throughout the individual’s stay in an inpatient facility and then back out into the community.

One of the problems is that this model runs counter to everything that has been taught before this.  For example, when I took psychiatry in medical school, I was taught that there were two types of psychiatric patients.  There was dementia praecox, which had to do with people who had delusions and hallucinations, who would gradually just get worse and worse until they were completely insane.  Then, there were psychopathic personalities who were individuals with very distorted personalities.  In either case, the question was, were these individuals treatable?

And so I was imbued with this story that severely mentally ill people, since they seemed so removed and so strange, were really untreatable.  Working with Paul Grant and the others on our schizophrenia team, we were able to discover that if we changed our philosophy to the ideas of Recovery and went on the assumption that underneath the abnormal symptoms, there was a normal personality, that we could maintain the personality.

But the problem was, how do you maintain the person?  Well, that becomes the problem.  So the plan became to train all the individuals that have contact with the patients–actually we call them “individuals.” This includes the art therapists, the occupational therapists, the social workers, the line staff, nurses and psychiatrists. We needed all of them to come aboard, using this new approach.  To do this, they needed a change in attitude, because many of them had the same erroneous belief that I had had—namely that the people who were insane by definition, were not capable of being sane at any time.  And we would have to create an atmosphere in which all of the personnel would work toward establishing a cognitive milieu.

Now, to accomplish that would be difficult, because there are numerous problems that the staff has to deal with, that get in the way of this full recovery.  For example, the most common problems are the negative symptoms.  Some of the severely ill individuals also act out in various ways or become aggressive toward the staff.  So numerous problems have come up, and the staff has had to learn how to deal with them.  But once they do, the individual can move along and get back into their lives.  Also, there is certainly turn-over at the various facilities, as staff comes in and out.

So, I expect that at the end of 5 years, we’re going to have a model program here at the Philadelphia Department of Behavioral Health and Intellectual Disability Services(DBHIDS), and people will come from all over the world to learn about the program.  Right now, we have national and international clinicians who are trying to learn our method and export it to their own home towns, and eventually we’ll have a training program that will involve not only people at DBHIDS but people from around the world.