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March 28, 2020
CT-R for Schizophrenia and Serious Mental Health Conditions

By Ellen Inverso, PsyD

Connection is a basic human need (Baumeister & Leary, 1995) and the foundational component of Recovery-Oriented Cognitive Therapy (CT-R). Connection can involve having a sense of unity with another person or group of people, feeling like you belong or are a part of something bigger than yourself, and taking opportunities to share your values and talents with others (Beck et al, in press). The impact is significant: social disconnection correlates with poorer physical health –including shorter life expectancy (Green et al, 2018);withdraw and isolation have been linked to increased rates of rehospitalization and longer inpatient psychiatric hospital stays for individuals with serious mental health conditions, such as schizophrenia (Patel et al, 2015); and social exclusion is connected to defeatist beliefs (e.g. “What’s the point of trying, I will just fail anyway;” “Failing part way is the same as failing all the way;” Reddy, et al, 2017). How do we help facilitate connection when the prescription for the country is separation?

For the Mental Health Provider: Helping Our Clients Stay Connected

With connection being so important for our mental health, we can encourage clients to refocus their energy and attention onto the things they can still do. If they successfully engage in these activities, we can then guide our clients to draw conclusions about their ability to connect, their worth, their contributions, and their resilience in navigating difficult and uncertain situations. Here are some ideas you can share with clients to pursue safe and meaningful connection during this time of social distancing:

Meaningful Roles at Home*

If there are others in the home:

  • Cook for your family or teach someone else in the home how to prepare a favorite meal
  • Hold daily family meetings where each person sets a goal for the day and supports each other in reaching them
  • Exercise together
  • Make home-oriented activities fun, like organizing clothes in the closet by putting on a fashion show
  • Teach each other your hobbies, such as crocheting, drawing, video games – any interest is worth sharing
  • Learn some phrases in a new language and practice together

If living alone:

  • Create art and share it with others online or via text message
  • Share humorous adventures of pets
  • Begin planning projects or create a vision board, connect to others through sharing or seeking new ideas

Home-based community service:

  • Write letters or draw pictures and mail them to others who cannot receive visitors because of the crisis, such as nursing home residents or individuals in hospitals
  • Find 3 things in each room that can be donated to those in need

Virtual connections to others – in small groups and more broadly:

  • Search for free online concerts, spiritual services, book clubs. Whatever the interest, there is an online forum available to bring people together, perhaps now more than ever
  • Share meals with extended family using video chat apps

You can support clients in making meaning from any of these activities by asking targeted questions that strengthen positive beliefs about themselves, others, and the broader community. Examples include:

  • “What does it say about you that you’ve been able to help your community in this way?”
  • “What is the best part of working together to stay connected?”
  • “You’re a pretty creative problem-solver, would you agree?”
  • “What does it say about you that you’ve been able to share your ideas with others and have them be accepted? Is it possible that you have a lot to offer and that you are a valuable member of your community?”

*All suggestions pertaining to home-based activities can be used in mental health settings such as inpatient units and programmatic residences, often with minimal adjustments necessary. Want to brainstorm ways to adapt this to your setting given its available resources or restrictions? Email us!

Connecting to our Clients with Empathy and Understanding

Empathy is our ability to relate to situations and feelings as human beings. While the impact of the current COVID-19 pandemic may vary from person to person, there have been a lot of changes – many happening very rapidly and with very little time for preparation. This experience can stir up a range of emotions – anxiety, confusion, discomfort – and can stir up beliefs about having little or no control, among other thoughts. By demonstrating that we can understand clients’ perspectives, we reduce the distance between us and strengthen our bond. We can communicate our understanding to clients in a few ways.

Empathic reflection:

  • “I hear you saying it’s been so difficult with the kids being home and trying to work. I imagine that can be exhausting. Is that how you are experiencing it?”
  • “I understand feeling a bit out of control right now.  I have had some thoughts about that, too. I wonder if it would be a good use of our time together to think of ways we can both try to feel more control in this situation. We can both have action plans at the end and see which strategies work best. What do you think?”

Share resources and ask for ideas:

  • This can be a great opportunity to learn from our clients. Do they have any suggestions of ways others (or you!) can de-stress? Do they have a favorite mindfulness exercise or hobby that takes their mind off the chaos?
  • If you learn something new, draw your client’s attention to how likely it is that their ideas will help you and others get through challenges. This is the epitome of connection, contribution, and purpose.

Bringing it All Together

In times of stress and uncertainty, there is great promise in coming together. Meaningful daily action, sharing our experiences and learning from each other, and being flexible and empathic are all ways to promote connection and empowerment in the face of challenges. Give yourself permission to think outside the box and be creative! We’re in this together!


Baumeister, R. F., & Leary, M.R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychol Bulletin, 117(3), 497-529.

Beck, A.T., Grant, P.M., Inverso, E., Brinen, A., Perivoliotis, D. (in press). Recovery-oriented cognitive therapy for serious mental health conditions. Guilford Press, New York.

Green, M. F., Horan, W. P., Lee, J., McCleery, A., Reddy, L. F., & Wynn, J. K. (2018). Social Disconnection in Schizophrenia and the General Community. Schizophrenia bulletin, 44(2), 242–249.

Patel, R., Jayatilleke, N., Broadbent, M., Chang, C-K., Foskett, N., Gorrell, G., Hayes, R. D., . . Stewart, R. (2015). Negative symptoms in schizophrenia: a study in a large clinical sample of patients using a novel automated method. British Medical Journal Open, 5(9).

Reddy, F., Reavis, E., Polon, N., Morales, J. & Green, M. (2017). The Cognitive Costs of Social Exclusion in Schizophrenia. Schizophrenia Bulletin 43, S54-S54.