New Breakthroughs in Cognitive Therapy: Applications to the Severely Mentally Ill (Part 2)
Aaron T. Beck, MD
Note: This article summarizes Aaron Beck’s interview with Judith Beck at the Evolution of Psychotherapy Conference in Anaheim, CA, December 16, 2017, for which he received a standing ovation from over 7,000 conference participants.
Read Part 1.
Incorporating Key Strategies from the Recovery Movement
While we were developing our treatment protocol for individuals with schizophrenia, we became aware of the recovery movement and formulated a new therapy incorporating the recovery objectives. We systematically operationalized a set of strategies to attain these objectives. Although our initial work was with an outpatient population, I posited that if this therapy were truly effective, then it should work on the most severely mentally ill. We established a contract with the state hospital and started to supervise the treatment of patients with severe mental illness. The steps that we followed with these long-term inpatients were:
- Establishing contact: Many of these patients were not readily approachable. One individual sat in the corner with a blanket over his head. Another stayed in his room all day and would not leave. The third sat in a chair hallucinating all day. One of our therapists was able to establish contact with the first individual by approaching him and asking whether he could recognize music she was playing from her phone. She continued to visit him, and during each visit he responded more readily to the music. After a week, he was aroused sufficiently to join some of the other patients who were either playing the piano or singing and dancing.
- Engagement: The next step was forming a close bond with the patient, which we call engagement. The engagement phase consisted of several elements. One was the importance of equalizing the relationship. Our staff member would collaborate with the patients on activities that were both pleasurable and meaningful to them, including playing games, asking for the patients’ advice, or going to the gym together. In one case, a staff member and a patient collaborated by building a birdhouse together. The next step was to elicit the individual’s aims, goals, and aspirations and so on. We did this through guided discovery, determining talents, strengths, past positive experiences, successes, etc.
- Formulation and Action Plan: The action plan provided a pathway to the individual’s aspirations, culminating in the individual’s feeling more efficacious, valued, and socially desirable. The objectives often involved regaining contact with family and friends, making new friends, going out on a date, or getting involved in meaningful jobs. The individual was likely to encounter many obstacles along the way, including psychotic symptoms, discouragement, and poor problem-solving. Staff would work together with the individual to address each of these problems as they arose. Indeed, many of these problems seemed to resolve as the individual returned to a state of increased wellbeing, including poor problem-solving, poor interpersonal relations, and overreaction to frustration.