What is Recovery-Oriented Cognitive Therapy and how can it offer renewed hope to individuals with severe mental health conditions? Q&A with expert trainer, Aaron Brinen.
Q
What is Recovery-Oriented Cognitive Therapy (CT-R)?
A
Recovery-Oriented Cognitive Therapy (or Recovery-Oriented CBTp) extends upon the original work of CBT, which focused on psychosis for individuals least likely to engage in psychosocial treatment. Often, these individuals have what’s referred to as the negative symptoms of schizophrenia: problems with motivation, expression and connection.
CT-R was developed using a specific cognitive model that conceptualizes negative symptoms as coming from unhelpful and inaccurate beliefs: lacking the ability to be successful, a disinterest in socializing, and lowered expectations for pleasure. These symptoms create a fertile ground upon which other positive symptoms thrive, such as hallucinations and delusions. They also create an initial hurdle for treatment providers to clear. An individual who has a significant reduction in motivation (that is, avolition) has a reduction in motivation for most activities, and psychotherapy is an activity.
Recovery-Oriented CBTp focuses on where the individual wants to go and views symptoms as obstacles to be addressed only as they impede action toward the individual’s aspirations. The treatment is active and focuses on correcting unhelpful beliefs by testing them out.
The provider starts by engaging the individual with the purpose of activating a set of beliefs that inhibits triggering the symptom-energizing beliefs. Once the individual is activated, the provider looks to elicit aspirations from personal, meaningful and valued pursuits. With those aspirations identified, the individual and the provider enrich them to increase vividness and motivation. Finally, the individual plans action towards these aspirations in life. These experiences of action provide plentiful opportunities to correct thoughts and beliefs, increase helpful routines to counter symptoms and achieve the desired life.
Q
What led you to become a co-developer of Recovery-Oriented Cognitive Therapy (CT-R)?
A
A series of fortunate events. I joined the Psychopathology Research Unit (later renamed the Aaron T. Beck Psychopathology Research Center) at the University of Pennsylvania. I worked on disseminating Cognitive Therapy in the community through a project with the City of Philadelphia. At that time, Dr Aaron T. Beck was completing the clinical trial for Recovery Oriented CBTp, which he supervised. I attended those supervisions regularly and joined as one of the final clinicians in the study.
One day at lunch, Dr Beck asked if I had experience running groups. He asked me to help run a ‘voices and paranoia’ group under the direction of Nadine Chang, PhD, at a local community mental health center. Nadine gave me a crash course in schizophrenia and I started to translate much of my anxiety disorder/PTSD understanding to schizophrenia.
Next, I joined a project implementing a CBT for psychosis approach in an inpatient hospital unit in Philadelphia. Dimitri Perivoliotis, PhD, coached me through intervening with individuals with psychosis, like a sort of CBTp boot camp. Dimitri developed a behavior plan that was the first iteration of the CT-R protocol.
Once the study was published, people started asking to be trained in this form of cognitive therapy. Nadine and Dimitri had gone on to new jobs and the team was asked to develop training for community therapists in Philadelphia and a large project in Georgia. We needed to create a set of training slides to teach this approach and then provide consultation to help change the clinicians’ behaviors. I took the slides and ways of teaching from the original dissemination project and started watching videos from the clinical trial.
I needed to figure out why each part of the treatment was implemented; what were the strategies for change that helped the individual correct the way they saw the world? As we trained clinicians, we also consulted on their treatments, which gave us further shaping to how the treatment worked. Additionally, I served these individuals over the full course of treatment development and refined the specifics of implementation. To this day, I continue to train, supervise and provide therapy to inform further developments.
More information is available at the following link:
Q
What types of presentations is Recovery-Oriented Cognitive Therapy (CT-R) useful for?
A
Recovery-Oriented CBTp is useful for individuals least likely to engage in psychosocial treatment. These individuals might struggle with motivation or connecting with others (that is, negative symptoms). They might have intense beliefs that interfere with benefiting from or engaging in treatment because they provide intense meaning for the individual or feel excessively protective (such as grandiose delusion or persecutory delusion). Individuals might have experiences that interfere with therapy and life, like excessive anger, distressing voices, or communication disturbances. CT-R provides a vehicle for treatment and initiation of other evidence-based approaches.
Q
When would you use Recovery-Oriented Cognitive Therapy (CT-R) vs Cognitive Behavioral Therapy for Psychosis (CBTp) for individuals experiencing psychosis?
A
This is a great question because it highlights a false dichotomy: that we either choose CBTp or CT-R. CT-R is an extension of CBTp for those least likely to engage in psychosocial treatments and prioritizes problems with motivation and connection. So, if someone shows up and identifies voice hearing as problematic or distressing because of their fears of others, the therapist might adopt a more formal CBTp approach. Oftentimes, CT-R shifts over the course of treatment and looks a lot like classic CBT (including setting an agenda, bridge and action plan).
Q
What are the phases or steps involved in the Recovery-Oriented Cognitive Therapy (CT-R) protocol?
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The CT-R protocol has three main parts that create the experiences for learning/cognitive restructuring: Activation, Aspirations and Action.
Activating the Adaptive Mode: Many times individuals are approached in sessions initially with clinical questions (regarding medications, therapy, hygiene and so on) and this elicits a patient mode (such as low motivation, increased beliefs of importance and increased voices). However, sometimes we just start asking about human things: “Oh heck, did you watch football yesterday?” In those moments, the person can come to life! This effect is seen with sports, food, holidays and other personally relevant topics. Also, this effect is seen when getting active (for example, watching a movie trailer, throwing a ball, or walking). This activating approach elicits an adaptive mode where the individual is more capable of increased adaptive thinking. Activation is a behavioral experiment to test beliefs interfering in therapy or activity.
Aspirations: Once the individual accesses the motivation, the provider elicits those big-picture aspirations that motivate all of us. The therapist uses aspiration as a north star for determining treatment targets and deciding what is relevant to address in treatment because it impedes forward progress. Also, aspirations provide a more personal activation topic and a reason to tackle more difficult therapy tasks.
Action: Once the individual has identified aspirations, they use action towards those aspirations to develop an activity schedule. Activity schedules provide a structure for implementing other interventions and a data collection, monitoring and analysis system for correcting beliefs. Early-in-treatment action is often increased as the individual notices the benefits from activation experiences in session.
Drawing Conclusions: The above protocol provides a rich set of experiences for the individual (such as increased energy, enjoyable connection with others, decreased worry and interrupted voice hearing). All those experiences can be used to learn new lessons about energy, connection, unfounded threat beliefs, or voice hearing. With this learning, they develop new behavioral routines to continue testing it out.
Videos:
Using the CT-R Protocol with More Precision: https://youtu.be/lpgvVuXct6I
Recovery-Oriented CBTp: Aspirations: https://youtu.be/cXiK26PGEdo
Behavioral Experiment: Testing It Out In Cognitive Therapy: https://youtu.be/42yn4sboXT0
Q
What treatment model(s) would you recommend for people who have serious thought and behavioral disturbances and complex problems such as homelessness, substance use and a history of trauma?
A
These complex questions draw providers to focus on what to do before figuring out why they are going to do it. Whenever considering the treatment model, start with developing an understanding (that is, conceptualization) of the driver(s) of the problem and for complex problems, how the drivers work together to sustain the dysfunction. Once you think through how the factors are interacting, collaboratively choose the first (and ideally most central) target. Substance abuse/misuse can be one piece of that cycle.
For example, if an individual stays up all night and walks around their house to protect their family from enemies because they hear voices reminding them of their trauma memories, the practitioner needs to start pulling this apart and figure out how the factors drive each other:
PTSD and intrusive memories → Anxiety and threat
Anxiety and threat → Worry and increased voice hearing
Worry and voice hearing → Sleep disturbance and unfounded threat belief
Sleep disturbance and fears → Walking around the house and triggers for memories
With this breakdown, the provider and individual might look at possible starts to treatment, such as memories using Prolonged Exposure or unfounded threat belief using the Feeling Safe Programme. CT-R can set a series of experiences and motivations to engage someone experiencing high crisis and develop a pragmatic treatment plan that increases a sense of manageability. Obscuring this cycle might be the individual’s use of substances to manage urges set off by the fear described above. Addressing the central cycle might reduce the need for substances. For others, specific interventions might be needed to disrupt the substance misuse.
If the problems are leading to or caused by challenges such as homelessness and food instability, the provider might suggest targeting the mental health issues, as these are often implicated in and complicate the resolution of real-world problems. Finally, we can teach and engage in focused problem-solving for these real-world problems, providing current solutions and a skill for the future.
Q
How could Recovery-Oriented Cognitive Therapy (CT-R) help clients who don't want to take medication for a psychotic illness?
A
Researchers in the UK have demonstrated that CBTp treatments are highly successful in the absence of medications (not to be conflated with the idea that medications are irrelevant). Further, psychiatrists have written on the questionable decision of long-term prophylactic treatment and the advantages of reducing the use of medicine if no benefits are observed. Also, pragmatically speaking, research on medications finds that many individuals switch medications throughout studies and many choose to go off their medicines.
While not studied formally, patients have been successfully treated with CT-R who choose not to take medicine, either because they refuse or cannot due to medical problems. CT-R does not have a prerequisite that the patient be stable on medications. This point is important considering a group of patients will never draw substantive relief from medications.
The treatment starts the same way if someone is not taking medications and progresses with the same formulations. CT-R’s collaborative nature makes the conversation about medicine less of a power struggle because the talk is in the context of easing action toward aspirations and not about an illness.
More information is available at the following link:
Q
How often do PTSD and psychosis co-occur? What should treatment involve when they do?
A
Individuals with schizophrenia often have a history of trauma, with reported incidences ranging from 43 to 81 percent. While most people who experience a traumatic event or series of traumatic events naturally recover, a higher proportion of individuals with serious mental illness do not. One set of symptoms that follow a traumatic event can be PTSD. Recent research has established the relationship between PTSD symptoms and psychosis symptoms.
Some studies of comorbid PTSD and schizophrenia spectrum diagnosis in the Netherlands found that the only treatment group that got worse was the wait list (the group that got no treatment), so the big message is to treat PTSD. The best treatments we have for individuals with psychosis and PTSD are ones that have an exposure element. The Dutch compared Prolonged Exposure and EMDR and found that both groups improved in PTSD symptoms.
Once we understand PTSD, this should make sense. PTSD is an unbridled anxiety generator that has unpredictable triggers, both internal and external. Psychosis is often thought of as a stress diathesis disorder. PTSD provides all the stress for the psychosis.
More information is available at the following links:
Q
What can help when a patient has a low desire to connect with the therapist (and others in their life)?
A
A reduced motivation to connect with others is one of the symptoms of schizophrenia—asociality—driven by a set of beliefs about disinterest in socializing. These beliefs moderate the individual’s competence in socializing and ability to experience the perspectives of others. This symptom is made worse by the provider’s behaviors in therapy. Therapy interactions that amplify the experience of the individual seeing themselves as a patient (asking about medications initially, discussions of hygiene, over-focusing on treatment) can activate these beliefs and reinforce the futility/aversiveness of socializing.
In CT-R, the therapist targets this symptom directly and immediately. The therapist starts with interactions that produce a high yield of enjoyment in socializing, such as talking about sports, going for a walk, or listening to a song. The goal is to produce an instant experience of the benefit of connection and then grow it in session, like building a campfire from a small spark to a big fire. Once the connection is made, the therapist draws the patient’s attention to the positive experience, the value of connecting and planning to try it out again in the future.
More information is available at the following link:
Q
How do you help when clients believe that they are broken and no one can help?
A
Sadly, this belief is common and the stigma/actual communication about psychosis or schizophrenia makes it worse, not better. Further, researchers have found a connection between a focus on insight (that is, illness explanation for experiences) and increased hopelessness. The approach is to treat the hopelessness belief first.
Use data to disabuse the individual of any fatalistic/broken brain messages they’ve been told: “So, you were told this is a progressive disease and you need to readjust your plans for life because they are unlikely to happen? Yeah, that is garbage. No evidence to support that statement. That’s an ancient out-of-date idea. Most people, 60 percent or more with these problems, recover and do well. It requires work, but you don’t seem afraid of a little work.”
Identify what lets them know their brain doesn’t work or that no one can help. Set small behavioral experiments to test out those ideas: https://youtu.be/42yn4sboXT0to
Aim for small, concrete changes to test out the hopelessness. For example, an individual who hears relentless voices and cannot see a world without them might engage in a small activity with you and experience the voices quietening down. This experiment is the first small crack in the hopelessness. Repeating these types of experiences leads to more hope: “So I get why you’d think it’s hopeless and look at these small changes…I wonder what more we can do?”
The key is not to promise the moon, but to promise a small possibility of a flicker of light.
Q
How does Recovery-Oriented Cognitive Therapy (CT-R) address the positive and negative symptoms of psychosis?
A
Positive symptoms (such as hallucinations and delusions) and negative symptoms (such as problems with motivation, connection and expression) are addressed in the context of an individual moving back towards their life. They are viewed as obstacles rather than problems to hunt down. For example, in some treatments, the provider would make a list of the problems that might include persecutory delusion, voices and motivation. In CT-R, the provider and individual work on identifying the aspiration and taking action toward that aspiration. When the individual (as a part of that plan) cannot go to the store because they fear others will harm them (that is, persecutory delusion), they develop a plan to target that obstacle in the context of the aspiration.
Initially, all problems are addressed with the basic protocol of CT-R (https://youtu.be/lpgvVuXct6I). The provider uses activation to interfere with the current symptom and plans to repeat that activity during the week. This cycle reduces time for the symptom and increases activity level. Once the symptoms recede enough, the provider elicits personal and meaningful aspirations to motivate the individual to take the risk to increase activity and develop an activity schedule (https://youtu.be/J6h9QPy4fYU).
Successes and changes in any of the symptoms provide an opportunity to restructure beliefs that maintain the symptoms.
If this basic protocol does not remediate the symptom, the provider will use effective interventions that target the symptom, continue the individual moving forward, and restructure beliefs regarding the symptom.
More information is available at the following link:
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