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What is Recovery-Oriented Cognitive Therapy (CT-R)?

By Jenna Feldman, Mike Best, Aaron T. Beck, Ellen Inverso, and Paul Grant

What is CT-R?

Based on Aaron Beck’s cognitive model, and embodying the principles and spirit of the recovery movement, Recovery Oriented Cognitive Therapy (CT-R) is a treatment approach designed to promote empowerment, recovery, and resiliency in individuals with serious mental health conditions. Expanding from Cognitive Behavioral Therapy for Psychosis (CBTp), CT-R is a strengths-based approach that focuses on activating adaptive modes of living, developing meaningful aspirations, and engaging in personally meaningful activities to bring about one’s desired life. Formulation in CT-R contextualizes challenges within the broader scope of an individual’s interests, values, and aspirations for a meaningful life.

What is the Difference Between CT-R and CBTp?

CT-R is a related treatment approach to CBTp. CBTp is primarily focused on symptom reduction as a way to reduce distress and enhance quality of life. By contrast, CT-R is focused on identifying and attaining the individual’s desired life. Interventions promote empowerment relative to challenges such as symptoms. CT-R is particularly applicable for people who might otherwise not engage in treatment due to mistrust, chronic institutionalization, limited access to motivation, limited verbalization, or intensity of symptom presentation.

Who is CT-R For and What Kinds of Challenges Do These Individuals Face?

CT-R focuses on empowering individuals with serious mental health conditions to live the life they want to be living. These individuals may experience challenges such as:

  • Difficulty accessing motivation
  • Difficulty connecting and communicating with others
  • Distressing voices and/or other forms of hallucinations
  • Beliefs that are hard for people to understand
  • Aggressive behavior
  • Self-injury
  • Impact of trauma
  • Disagreement regarding the presence of a mental health condition

CT-R is grounded in the premise that recovery is possible for all, no matter how long an individual has been experiencing these challenges or how difficult these challenges appear. By focusing on each individual's personal vision of their mission in life rather than symptom reduction, CT-R empowers individuals with serious mental health conditions to flourish.

Empirical Support for CT-R

CT-R was initially developed to promote recovery for individuals experiencing significant difficulties accessing motivation (traditionally referred to as negative symptoms). Although difficulties with motivation have traditionally been understood from a biological perspective, Paul Grant and Aaron Beck identified defeatist performance beliefs (such as “Taking even a small risk is foolish because the loss is likely to be a disaster,” and “If I fail partly, it is as bad as being a complete failure”) as being associated with difficulty accessing motivation (Grant & Beck, 2009). Similarly, asocial beliefs such as, “I prefer hobbies and leisure activities that do not involve other people,” and “People sometimes think I am shy when I really just want to be left alone,” are related to the degree to which individuals participate in social activities (Grant & Beck, 2010). Given the importance of these beliefs in predicting motivation and community participation (Thomas et al., 2017), CT-R was developed as a method of deactivating these beliefs and activating more adaptive beliefs that promote empowerment and recovery. In a randomized clinical trial, CT-R improved community participation, motivation, and positive symptoms to a greater extent than treatment as usual (Grant et al., 2012). Improvements from CT-R were also maintained 6-months after treatment ended (Grant et al., 2017). Perhaps most importantly, gains were experienced regardless of the individuals’ duration of illness.

Implementation of CT-R

CT-R can be used in either individual or group-based settings and is especially useful in the treatment milieu. CT-R has been successfully implemented in Pennsylvania, New Jersey, New York, Georgia, Massachusetts, Montana, Delaware, Virginia, and Vermont in a broad range of settings:

  1. Community Teams
    • Assertive Community Treatment Teams (fidelity and non-fidelity)
    • Coordinated Specialty Care Teams
    • Mobile Crisis Teams
    • Jail Diversion Teams
  2. Hospital
    • State Hospitals (Civil and Forensic)
    • Long-Term Hospital Units (Extended-Acute)
    • Acute Hospital Units
  3. Residential
    • Programmatic Residences (locked and unlocked, forensic and civil)
    • Supportive Housing
  4. Outpatient (group and individual)
    • Veterans Administration)
    • Community Mental Health Centers
    • Ultra-High Risk Youth

Treatment Process

CT-R focuses on actualizing adaptive and desired modes of living through the development of personally valued aspirations and participation in daily activities that realize their underlying meaning.

Accessing and Energizing the Adaptive Mode

The first stage of CT-R focuses on accessing the person’s best self through shared activity, such as listening to music, watching videos, going for a walk, enjoying a coffee or some food, discussing sports or travel, or focusing on something they are an expert in. This is a way to develop connection and trust and avoid activating the beliefs that discourage people with mental health challenges from engaging with others. The term adaptive mode captures the positive beliefs, emotion, and actions that appear when individuals are at their best. Once it is clear how to access an individual’s adaptive mode, we help energize and build up this way of being with an expanding and predictable array of activities– drawing conclusions during each experience about feeling energized, doing things with others, doing things more often, etc.

Developing the Adaptive Mode Through Aspirations

Expanding upon a problem-centered approach to goal-setting, CT-R emphasizes developing personally worthwhile and life-orienting aspirations. We work with individuals to create a vivid and powerful image of their desired future. Central to this is identifying the meaning underneath the aspiration. For example, the underlying meaning of becoming a nurse could be to help people and make the world a better place; the underlying meaning of having a partner could be to share good experiences and have mutual support when the going gets tough. Developing aspirations spurs hope, elicits values, and orients daily action to achieve purpose and contextualize challenges.

Actualizing the Adaptive Mode Through Positive Action

Positive action brings the underlying meaning of the person’s aspirations into everyday life.  Hope actively co-mingles with life purpose.  For example, the person who wants to be a nurse and have a partner can pursue a myriad of different activities to help people, which is a great way to connect with them. During these activities, the person can strengthen beliefs about being capable of getting the life they want and being able to make a difference in the world. Regular experience of achieving the meaning of one’s aspirations can have a profound impact: the adaptive mode is actualized, potential is realized, momentum is established, and progress is palpable.

Strengthening the Adaptive Mode – Empowerment and Resiliency

Action towards realizing aspirations naturally stirs up challenges such as those listed above. CT-R emphasizes empowerment relative to experiences provoked by stress, things not going as planned, rejections, disappointments, etc. During trying times, the key is to maintain focus on that which is most valuable– one’s aspirations, connections and their personal meanings. The cognitive model helps us to understand the negative beliefs that give rise to challenges, but also the positive beliefs that can help shift the focus back to the adaptive modes of living. Interventions help the person to foster this shift from challenge-focused to the adaptive mode– embodying empowerment.

We help individuals strengthen their adaptive mode and experience their best self, strengthening positive beliefs, especially those related to energy, capability, control, and connection. By building these positive beliefs the adaptive mode becomes the dominant mode, and the individual begins an upward spiral toward their desired life.

Resiliency is fostered by strengthening positive beliefs about one’s ability to overcome challenges; when feeling empowered with respect to challenges, individuals become more and more willing to take the risk of pursuing their dreams.

Summary and Conclusion

Grounded in the empirically-supported cognitive model and a strengths-based, person-centered, human-potential-focused view of recovery and resiliency, CT-R is nurturing deep wellsprings of hope and empowering individuals with serious mental health conditions to actively experience the type of flourishing life they want to live.

References

Grant PM, Beck AT. (2009). Defeatist Beliefs as a Mediator of Cognitive Impairment, Negative Symptoms, and Functioning in Schizophrenia. Schizophrenia Bulletin, 35(4), 798–806.

Grant PM, Beck AT. (2010). Asocial Beliefs as Predictors of Asocial Behavior in Schizophrenia. Psychiatry Research, 177, 65-70.

Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients with Schizophrenia. Archives of General Psychiatry, 69(2), 121-127.

Grant PM, Bredemeier K, and Beck AT. (2017). Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals with Schizophrenia. Psychiatric Services, 68(10), 997-1002.


Upcoming Workshop

CT-R for Serious Mental Health Conditions

April 24-26, 2019