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New Pathways in Cognitive Therapy for Severe Disorders

By Aaron T. Beck, MD

The standard cognitive therapy approach may be insufficient for more severe disorders, especially schizophrenia. For this reason, it is imperative to map out the ways in which Recovery-Oriented Cognitive Therapy (CT-R) addresses these disorders and successfully and collaboratively works with individuals to reach their aspirations and stay on the pathway toward recovery.

  1. Importance of the Interpersonal Relationship: A good, solid working relationship is essential for Recovery-Oriented Cognitive Therapy (CT-R). In addition to the standard collaborative relationship with emphasis on understanding and the provision of support, the therapist using CT-R is more personally involved with the individual. In this approach, there is a blending of the relationship with actions. The therapist/clinician/staff person works collaboratively with the individual by doing engaging and energizing activities together such as walking, playing catch, or building a birdhouse.  As the relationship progresses, the clinician acquires important information about specific activities, skills, and talents that are meaningful to the individual (e.g., sports, games, travel, cooking, pets) and tailors the activities to these particular interests. After they have forged a strong relationship, an individual’s reaction to his or her therapist could be, “He /she believes in me and now I believe in myself.”
  2. Identifying Aspirations: The aspirations represent an important organizing principle for mobilizing the individual’s motivation and effort. Focusing on aspirations helps to facilitate dealing with the various obstacles and challenges along the road to recovery. The aspirations may take an intangible form such as “getting my life back together again” or “being a better person,” but these goals are translatable into concrete experiences, such as helping other people.
  3. Meaning: The aspirations and the activities are not the crucial elements in themselves. Instead, these aspirations and specific experiences have meanings that increase the individual’s self-esteem, control, and connectedness. Thus, a meaning of a particular aspiration or experience might be about the individual’s perception of him- or herself, e.g. “I am respected, worthwhile, safe, effective—a good person,” or about others’ perception of the individual, e.g. “Other people also respect, accept, and like me.”
  4. Connection: Every contact with an individual should be therapeutic. This includes contact with line staff, professional staff, and incidental staff such as cooks and janitors.
  5. Conceptual Framework for Developing Formulation of Case: For each negative and dysfunctional belief, there is a positive counterpart. Moreover, the activation of these two sets of beliefs works in a reciprocal manner, namely, when a dysfunctional belief is activated, the corresponding positive or adaptive belief is deactivated and vice versa. For example, sociality would take the place of asociality, motivation for amotivation, and pleasure for anhedonia. These positive elements should represent the goals to be achieved.
  6. Development of Treatment/Action Plan: This plan is designed to provide meaningful experiences that will enhance the individual’s positive attributes and negate their dysfunctional beliefs. In trying to achieve this goal, it is necessary to identify the individual’s aspirations, make them alive, and then work on the necessary steps to satisfy the aspirations. This involves the preparation of a Recovery Map listing the steps, problems, challenges, and ways of dealing with these potential roadblocks. The therapeutic experiences along the way to recovery are designed specifically to increase the individual’s empowerment, self-esteem, control, and connections to other individuals.
  7. Personal Values, Purpose, and Commitment: The treatment plan takes into consideration the individual’s values and sense of purpose. Some individuals may find a mission in life, for example, helping other people. Being of assistance to the needy is often a pillar of the therapeutic experience. Faith-based activities may also provide a feeling of inspiration.
  8. Affective Experience: Generation of positive affect is important in the therapeutic impact of experiences. As conceptualized by Franz Alexander, the positive interpersonal relationships with others lead to “a corrective emotional experience.”
  9. Drawing Conclusions from Experiences: As used in standard Cognitive Therapy, it is important to underscore the learning from each successful experience to bring about enduring belief change.
  10. Imagery: Inducing images can be a powerful tool for revivifying past positive and contemplated experiences, including aspirations. The use of imaging, especially when associated with the appropriate affect, can make these experiences real.
  11. Therapeutic Use of Delusions: It is often possible to tease out the meaning of the delusions. These provide further information about the individual’s needs, wishes, and fears. This idea is applicable to very strongly held beliefs in some non-psychotic disorders such as borderline personality disorder.
  12. Theory of Modes: I have introduced the concept of modes to better understand each specific phase of a given disorder. Thus, we have the depressive mode, manic mode, anxious mode, psychotic mode, regressive mode, and so on. When a dysfunctional mode is activated, the disorder becomes operational. As mentioned previously, the thrust of treatment is to deactivate the mode by deactivating the dysfunctional beliefs and activating positive beliefs. Our goal is to activate the adaptive mode, free of the encroachment of one of the dysfunctional modes. In psychosis for example, individuals often flip from the psychotic or regressive mode to the adaptive mode when they become engaged in a meaningful activity.
  13. Resilience: During therapy, the individual learns to master the kinds of frustrations, challenges, and disappointments that he or she will have to face when living independently. The focus is on learning to activate the positive beliefs and deactivate the negative beliefs. It is assumed that the individual already has a store of methods for dealing with problems and the goal is to increase access to these internal resources when problems occur.
Summary: The three key words that best epitomize the CT-R approach are as follows: connection, empowerment, and resilience.