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.
Background: Individuals with identical symptomatology may receive conflicting diagnoses, potentially leading to different treatments. The aims of this study were to assess diagnostic impressions and treatment recommendations for obsessive–compulsive disorder (OCD) versus schizophrenia-spectrum disorders (SSD).
Methods: Participants (N = 82) were recruited from accredited doctoral programs. All participants were randomized to assess diagnostic impressions and treatment recommendations for 15 vignettes. These were measured across three separate testing sessions.
Results: Large discrepancies in treatment recommendations were found. All participants who selected OCD recommended psychotherapy while only 15.4% of participants who identified the same vignette as schizophrenia suggested psychotherapy. More than half the participants who reported schizophrenia selected antipsychotics as the primary response; medication was not a primary recommendation when the vignette was identified as OCD.
Conclusion: Symptoms conceptualized as SSDs were recommended medication; those same symptoms conceptualized as OCD were recommended psychotherapy. Greater awareness regarding the efficacy of psychosocial treatments for SSDs is needed.
Hunter, N., Glazier, K., & McGinn, L. K. (2015). Identical symptomology but different diagnoses: Treatment implications of an OCD versus schizophrenia diagnosis. Psychosis: Psychological, Social and Integrative Approaches. doi:10.1080/17522439.2015.1044462
Background: Cognitive behaviour therapy (CBT) is recommended for the treatment of psychosis; however, only a small proportion of service users have access to this intervention. Smartphone technology using software applications (apps) could increase access to psychological approaches for psychosis. This paper reports the protocol development for a clinical trial of smartphone-based CBT.
Methods/Design: We present a study protocol that describes a single-blind randomised controlled trial comparing a cognitive behaviour therapy-informed software application (Actissist) plus Treatment As Usual (TAU) with a symptom monitoring software application (ClinTouch) plus TAU in early psychosis. The study consists of a 12-week intervention period. We aim to recruit and randomly assign 36 participants registered with early intervention services (EIS) across the North West of England, UK in a 2:1 ratio to each arm of the trial. Our primary objective is to determine whether in people with early psychosis the Actissist app is feasible to deliver and acceptable to use. Secondary aims are to determine whether Actissist impacts on predictors of first episode psychosis (FEP) relapse and enhances user empowerment, functioning and quality of life. Assessments will take place at baseline, 12 weeks (post-treatment) and 22-weeks (10 weeks post-treatment) by assessors blind to treatment condition. The trial will report on the feasibility and acceptability of Actissist and compare outcomes between the randomised arms. The study also incorporates semi-structured interviews about the experience of participating in the Actissist trial that will be qualitatively analysed to inform future developments of the Actissist protocol and app.
Discussion:To our knowledge, this is the first controlled trial to test the feasibility, acceptability, uptake, attrition and potential efficacy of a CBT-informed smartphone app for early psychosis. Mobile applications designed to deliver a psychologically-informed intervention offer new possibilities to extend the reach of traditional mental health service delivery across a range of serious mental health problems and provide choice about available care.
Bucci, S., Barrowclough, c., Ainsworth, J., Morris, R., Berry, K., Machin, M., Emsley, R., Lewis, S., Edge, D., Buchan, L., & Haddock, G. (2015) Using mobile technology to deliver a cognitive behaviour therapy-informed intervention in early psychosis (Actissist): Study protocol for a randomised controlled trial. Trials Journal, 16 doi:10.1186/s13063-015-0943-3
Background Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.
Methods We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16–65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432.
Findings 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of ?6·52 (95% CI ?10·79 to ?2·25; p=0·003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose).
Interpretation Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed.
Bera, S.C., & Sarkar, Siddharth (2014). Cognitive therapy for patients with schizophrenia. The Lancet. 384 (9941), 401. DOI: http://dx.doi.org/10.1016/S0140-6736(14)61274-5
OBJECTIVE: Clinical responsiveness to cognitive behavioural therapy for psychosis (CBTp) varies. Recent research has demonstrated that illness perceptions predict active engagement in therapy, and, thereby, better outcomes. In this study, we aimed to investigate the psychometric properties of a modification of the Illness Perceptions Questionnaire (M-IPQ) designed to predict response following CBTp.
METHODS: Fifty-six participants with persistent, distressing delusions completed the M-IPQ; forty before a brief CBT intervention targeting persecutory ideation and sixteen before and after a control condition. Additional predictors of outcome (delusional conviction, symptom severity and belief inflexibility) were assessed at baseline. Outcomes were assessed at baseline and at follow-up four to eight weeks later.
RESULTS: The M-IPQ comprised two factors measuring problem duration and therapy-specific perceptions of Cure/Control. Associated subscales, formed by summing the relevant items for each factor, were reliable in their structure. The Cure/Control subscale was also reliable over time; showed convergent validity with other predictors of outcome; predicted therapy outcomes; and differentially predicted treatment effects.
LIMITATIONS: We measured outcome without an associated measure of engagement, in a small sample. Findings are consistent with hypothesis and existing research, but require replication in a larger, purposively recruited sample.
CONCLUSIONS: The Cure/Control subscale of the M-IPQ shows promise as a predictor of response to therapy. Specifically targeting these illness perceptions in the early stages of cognitive behavioural therapy may improve engagement and, consequently, outcomes.
Marcus, E., Garety, P., Weinman, J., Emsley, R., Dunn, G., Bebbington, P., Freeman, D., … Jolley, S. (December 01, 2014). A pilot validation of a modified Illness Perceptions Questionnaire designed to predict response to cognitive therapy for psychosis. Journal of Behavior Therapy and Experimental Psychiatry, 45, 4, 459-466.
In this video from a recent Beck Institute Workshop, Dr. Aaron Beck and Dr. Judith Beck discuss the effects of combining CBT and medication in the treatment of depression and schizophrenia. They also compare research findings on CBT treatment alone, medication alone, and a combination of CBT and medication among clients with severe depression and schizophrenia.
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In this video from a recent Beck Institute Workshop, Dr. Aaron Beck describes how to modify and utilize cognitive restructuring with a schizophrenic client. Using an example, Dr. Beck explains that he will initially focus on the client’s interests to build engagement and self-efficacy. As self-efficacy increases, the client’s problematic and unhelpful behaviors begin to decrease. Dr. Beck emphasizes the use of cognitive conceptualization to target the variables that drive the client’s behavior, which can be used to structure treatment.
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Support for cognitive-behavioral therapy (CBT) for psychosis has accumulated, with several reviews and meta-analyses indicating its effectiveness for various intended outcomes in a broad variety of clinical settings. Most of these studies, however, have evaluated CBT provided to the subset of people with schizophrenia who continue to experience positive symptoms despite adequate treatment with antipsychotics. Despite several reviews and meta-analyses, a specific estimate of the effects of CBT for patients with medication-resistant positive symptoms, for whom CBT is frequently used in outpatient clinical settings, is lacking. This meta-analysis examined CBT’s effectiveness among outpatients with medication-resistant psychosis, both on completion of treatment and at follow-up.
Systematic searches (until May 2012) of the Cochrane Collaborative Register of Trials, MEDLINE, PsycINFO, and PubMed were conducted. Sixteen published articles describing 12 randomized controlled trials were used as source data for the meta-analysis. Effect sizes were estimated using the standardized mean difference corrected for bias, Hedges’ g, for positive and general symptoms.
The trials included a total of 639 individuals, 552 of whom completed the posttreatment assessment (dropout rate of 14%). Overall beneficial effects of CBT were found at posttreatment for positive symptoms (Hedges’ g=.47) and for general symptoms (Hedges’ g=.52). These effects were maintained at follow-up for both positive and general symptoms (Hedges’ g=.41 and .40, respectively).
For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication.
Burns, A., Erickson, D., & Brenner, C. (2014). Cognitive-behavioral therapy for medication-resistant Psychosis: a meta-analytic review. Psychiatric Services. doi: 10.1176/appi.ps.201300213
In this video from a recent Beck Institute Workshop, Dr. Aaron Beck describes the shift in treatment aims for clients with Schizophrenia. He explains that previously “getting better” meant a decrease in symptoms of delusions and hallucinations. Today, Cognitive Behavior Therapy (CBT) aims to help clients function in their communities, whether or not they still experience symptoms. Dr. Beck goes on to say that when clients reintegrate into society, overall adaptive functioning typically improves.
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