Transformation: Recovery Oriented Cognitive Therapy for Schizophrenia

Paul Grant will be presenting as part of the advancing recovery through new research program track scheduled for July 6 at the 2016 NAMI National Convention. 

A common image of schizophrenia is the person who spends all day staring at the wall. Such loss of motivation and social withdrawal are known as negative symptoms. These are the most disabling features of this condition, and have been considered virtually permanent—no treatment has been discovered that would help to alleviate them.

In the late 1990s, we decided to see if we could understand negative symptoms better and find a way to improve them. The prevailing belief in the field has been that the observed social withdrawal and inactivity is based on impairment of brain function, specifically, attention, memory and executive function.  However, we could not comprehend how these impairments could translate into the profound inactivity we saw in the person staring at the wall.

After conducting many interviews with individuals experiencing negative symptoms, we came to a startling conclusion: these individuals appeared to have a system of negative beliefs that could account for their low functioning. Specifically, we speculated that defeatist and asocial beliefs reduce access to the motivation needed to initiate and sustain activity. The defeatist beliefs consisted of attitudes such as “there’s no sense in trying anything, I’m only going to fail,” and “failing at one thing is the same as being a total failure.” The asocial beliefs included "people are better off if they stay aloof from emotional involvements with most others,” and "making friends isn't worth the energy it takes.”

We conducted a series of studies and found, as predicted, that these negative attitudes had a direct impact on the negative symptoms, while the impairments in attention, memory, and executive functioning had only an indirect effect. It stood to reason that if we could modify these disabling attitudes, then we could relieve the disabling behavior.  

We began formulating our therapy based upon this basic science. At the same time, we were sharing our ideas with champions of the recovery movement—notably, Dr. Arthur Evans, Ph.D., Commissioner of Philadelphia’s Department of Behavioral Health. The dysfunctional beliefs we had identified were obstacles to recovery. A third study we conducted discovered that the therapy promoted recovery by targeting these beliefs and included forming an emotional and energizing engagement with the individual, eliciting their unique meaningful aspirations, breaking down and planning action towards the goals, drawing conclusions regarding the meaning of each success experience, identifying and mastering the obstacles to reaching these goals. 

In a randomized controlled trial, we recruited individuals with elevated negative symptoms and demonstrated that recovery-oriented cognitive therapy improved global functioning, reduced amotivation (the inability to see value in an activity), and reduced positive symptoms relative to standard care (medications, targeted case management, etc.) in the community. It seemed to us that the therapy produced a cycle of recovery in which the more the individuals were doing, the more their motivation increased, and the less time they had to dwell on hallucinations and delusions, which freed up more time to do meaningful activities, increasing motivation further, and lessening hallucinations and delusions further.

One observation that stuck with us from the clinical trial is the increased morale and motivation the individuals experienced when helping others. We realized that the sense of isolation and not belonging could be ameliorated with group activities that included teamwork that countered asocial beliefs. We developed milieu programming—for hospital and residential settings—that featured sports, plays, group singing and dancing, fashion shows, exercise, etc. This programming produced a transformation in the individuals’ affect, demeanor, and functioning. In fact, when the staff also joined in these activities, it was not possible to distinguish individuals from the staff.  This suggested to us that the delusions, hallucinations, and disorganization served to camouflage what was, essentially, a normal personality. Our therapy, thus, was geared to activate the adaptive personality through the relationships with the therapist, staff, and other individuals, in addition to the various activities, that they engaged in. 

Returning to the individual who spent most of his time sitting in a chair staring at the wall: after decades of little progress, he was able to succeed in the community, and in fact, had a girlfriend and was able to get a job. Nearly three-quarters of the individuals, in one of the hospital systems, showed similar improvement in their recovery during the first sixth months of supervised therapy. This program is a new approach that can provide hope of recovery from this very disabling disorder for even the most withdrawn individuals.

Dr. Beck is an emeritus professor in the Department of Psychiatry at the University of Pennsylvania and the director of the Aaron T. Beck Psychopathology Research Center. Paul M. Grant, Ph.D., is a Research Assistant Professor of Psychology in Psychiatry in the Aaron T. Beck Psychopathology Research Center in the Perelman School of Medicine at the University of Pennsylvania.