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.
by Aaron T. Beck, MD
Part 3 of 3
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.
Kimberly Grocher, LCSW traveled from NYC to attend 3 days of experiential training in CBT for Personality Disorders and Challenging Problems. She works at Weill Cornell Medical College in a group psychiatry practice where she treats clients of all ages, specializing in treating adult women with anxiety and PTSD, couples, and professionals.
As a “movement oriented therapist”, CBT resonates with her personal beliefs that feelings and goals start with thoughts.
She decided to attend training at Beck Institute because, “they are the best; this is the home of CBT. Where else to learn than from the source?”
The opportunity to meet Dr. Aaron Beck and collaborate with people from around the world were her favorite parts of the training. “This has just been amazing”
Kimberly also would like to acknowledge Weill Cornell Psychiatric Specialty Center, the Training Institute for Mental Health, and Fordham University (where she will be starting her PhD in the fall).
During a recent Beck Institute Workshop, Dr. Aaron Beck explains that in recent years eastern philosophies and religions have had an increased influence on CBT and which have been incorporated into mindfulness based cognitive therapy, acceptance and commitment therapy, and dialectic behavior therapy. In discussing DBT, he emphasizes the importance of validation with borderline personality disorder patients.
For CBT resources, visit our website.
According to a recent study published in European Psychiatry, a combined treatment, including cognitive behavior therapy (CBT), psycho-education, and pharmacology results in greater long-term efficacy in patients with refractory bipolar disorder than standard pharmacological treatment.
The current study is a 5-year follow-up to a previous trial which examined the differences in efficacy for patients (n=40) with treatment resistant bipolar disorder who were randomly assigned to an experimental group that used a combined therapy, or control group that used pharmacology alone. There were multiple evaluation points (6-months, 12-months, and 5-years) and at each follow-up, the between-group differences remained significant.
At all follow-up points, the combined therapy group had lower depression and anxiety scores. They also showed significant differences in mania and maladjustment at post-treatment, which were sustained through the 6-month, 12-month, and 5-year evaluation points. Further, the experimental group had fewer hospitalizations at the 12-month evaluation point. At the 5-year follow-up, 88.9% of patients who received pharmacological treatment alone continued to show persistent affective symptoms and/or difficulties in social-occupational functioning, compared to just 20% of patients who received the combined therapy treatment.
These findings suggest that a combined therapy, including CBT, psycho-education, and pharmacology may be quite helpful for patients with refractory bipolar disorder in the long term and superior to pharmacological treatment, alone.
González, I. A., Echeburúa, E., Limiñana, J. M., & González-Pinto, A. (2012) Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: A 5-year controlled clinical trial. European Psychiatry. In Press
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