Transformation: Recovery Oriented Cognitive Therapy for Schizophrenia

MAR. 16, 2016

By Aaron T. Beck, M.D., and Paul Grant, Ph.D

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. 

i. What NAMI requested: Listing of where the treatments are (including other setting, not just hospitals).

Our response: For treating severe mental illness, the Aaron T. Beck Center certifies clinicians in Recovery-Oriented Cognitive Therapy in hospitals, assertive community treatment teams, intensive residential programs, and outpatient individual and group therapy. To find a certified provider in South Eastern Pennsylvania, New Jersey, New York City, Delaware, and Massachusetts, contact recovery@aaronbeckcenter.org. To find a certified provider in the state of Georgia, contact Ursula Davis (udavis@gsu.edu). Unfortunately, we do not currently have availability to provide individual therapy for new clients with severe mental illness at our University of Pennsylvania Center. For disorders other than severe mental illness, the Academy of Cognitive Therapy website is a good resource for locating a qualified practitioner (www.academyofct.org); those in the Philadelphia area might consider the Beck Institute (www.beckinstitute.org).

ii. What NAMI requested: How people can ask their own health care provider about cognitive therapy?

Our response: Consumers and families can ask their mental health providers about cognitive therapy, and whether they have been trained or would be interested in training. The Aaron Beck Center is focused on training systems of care, both public and private, in recovery-oriented cognitive therapy for individuals with severe mental illness. For individual practitioners who might be seeking training, the Beck Institute (www.beckinstitute.org) offers workshops in recovery-oriented cognitive therapy provided by our center’s experts.  

iii. What NAMI requested: Some NAMI Affiliates have considered advocating their local mental health center to add cognitive therapy, which means training for some, for example. It would be interesting if you could share your knowledge on this scope. 

Our response: NAMI and other mental health advocacy groups can play a critical role in ensuring individuals and loved ones receive treatments that can actually realize the ideals of recovery and return them to the life they would like to be pursuing. Funding for effective and sustainable training is often the sticking point. We advocate a system-wide implementation model of CT-R that can coordinate care for individuals with severe mental illness to realize their recovery ambitions and reintegrate into the community. Our implementation model involves both training and supervision, culminating in an assessment of competency. We find that the vast majority of clinicians flourish in this approach and are able to promote recovery with individuals that they previously thought too difficult and treatment refractory. It is empowering to see a life become re-energized, as hope develops, and meaningful connections with others blossom. That such transformations also pose considerable financial savings to the systems serving these individuals is a true win-win arrangement.

Comments

Comments
SEP, 07, 2017 10:41:43 AM
Stephen H.East
I hope you care because I'm going to try. Here's a little true story. A psychiatrist cured a repression of mine. I had OCD/ Schizophrenia, I didn't follow through and he later died. This is what I've learned. You train the subconscious to give up it's secrets by reading the reoccurring, repetitive, predictable thought pattern aloud, in brief word groups, word for word as the patient free associates. Spread it out over the course of three and a half months till the patient acts out the repressed experience and relates it to the therapist. Get the patient to face it so the therapist can reverse them. The patient should follow through with the therapy. I swear dead childhood pets are a primary cause of repression.

MAY, 19, 2016 02:23:58 AM
Hanna
My son, 33 is suffering with Schizophrenic/Schizoeffective dissorder for about 12 years. He is NOT taking any meds and NOT seeing any Dr. He's been fouthfully hospitalized at least 12 times in different cities and even countries, but he is still in denial. His symptoms getting worse and worse and I feel extremely helpless.
Please help!!!
Thank you!

APR, 10, 2016 07:32:51 PM
Robert brown
All the research, studies and Rx in the world is only as good as the delivery system as can be seen in most of the comments relating to the lack of appropriate care, availability, money and politics. Hello Texas!

APR, 07, 2016 12:05:04 AM
DD
Positive experience, building self confidence and having fun is key to recovery. My son is diagnosed with schizophrenia and spent over 100 days in the hospital last year. I encourage everyone to read the book "The Center Cannot Hold." It has been my manual and my son is attending community college with a 4.0 and doing great! He quit smoking cigarettes, takes his meds and slowly added classes. His second semester back in college and is up to 10 credits. He has weekly psychotherapy that keeps him on task. Social activity and regaining confidence is key.

APR, 04, 2016 10:58:02 AM
Maria Rundle
Wonderful article! Yes, helping others is a key to recovery. Yes, being part of a team involved in meaningful work and activities is healing. I especially love the observation that "when the staff also joined in these activities, it was not possible to distinguish individuals from the staff."

My only quibble with this great article is the idea that this program is a "new approach." Gould Farm has been dedicated to this treatment model for over a century. The combination of authentic community, meaningful teamwork, and clinical care has supported recovery for generations of people living with mental health challenges. I have lived and worked at Gould Farm for eight years, sharing my life with people seeking recovery and moving towards greater independence. If you're interested in knowing more, please check out www.gouldfarm.org. And *thank you* to Dr. Beck and Dr. Grant for this important work!

APR, 04, 2016 10:43:17 AM
Sandra
I work at a mental health facility in Arkansas and there are some out patients day treatment centers here, such as counseling and associate, Arkansas counseling. You just have to research mental health out patient day treatment centers and see which one is best for you and your needs..

APR, 04, 2016 09:19:30 AM
Joanne LaConti
I would like to know about the group and social settings.
This is exactly what my son needs in his recovery.

APR, 02, 2016 10:46:23 AM
robert diamond
Can I get this treatment in Chicago?

APR, 01, 2016 06:33:48 PM
Greta kapadia
Help

APR, 01, 2016 06:33:20 PM
Greta kapadia
More info and how to get help.

APR, 01, 2016 02:42:55 AM
Usha
My son has lot of negative symptoms . Is there any program you can recommend near Southern California .

MAR, 31, 2016 08:53:33 PM
Michelle
To me this is common sense. The problem is where to find it. My daughter is 26, diagnosed with schizophrenia a few years ago after tragic losses and heavy substance abuse. She is now in a group home through the system, that I am very grateful for. She is not on the street right now, she is safe. But there is no stimulation, no interaction, no motivation. I see her slipping. I spent 1 day a week with her. I work full time and she is 45 minutes away. During those few hours I try to stimulate some and do see improvement. Then she goes home to a house full of people with no motivation or activity. We need motivated staff first. I continue to hope for improvement until it truly is available

MAR, 31, 2016 07:34:27 PM
Jolan Smith
We are all seeking a breakthtough treatment for either ourselves or someone dear to us. I am desperate for answers as to how to find a provider willing to use this therapy in Pennsylvania. Any advice would be deeply appreciated. I can be reached by email.

MAR, 31, 2016 06:07:56 PM
Lilacs
Where are these programs available? And at what cost?

MAR, 31, 2016 04:06:31 PM
Christie
Last week, I had a hard time simply waiting my 30 minute + turn to be considered for treatment at our local County Mental Health facility (8 miles away and free of charge.) I walked out of my appointment. Unfortunately, I will continue paying the extra dollars to see my private and out-of-network psychiatrist who is 30 minutes away from my home. With that being said, I can barely make it through the wait to talk to anyone. The over stimulation of others conversation and presence in the room is terrifying for me. It feels like drowning in deep dark water inside of my mind.

How can I benefit from cognitive therapy in a group setting? The thought of being part of a team, well... I'm on the verge of tears thinking about it. Seriously.

Schizophrenia is a life taker.

MAR, 31, 2016 01:39:28 PM
Barbara
I would like to open the discussion to include those who are caring for the developmentally/intellectually disabled who, in their 20s or 30s, also develop behavioral/mental illness. I never knew this could happen. Frightening to watch a practically non-verbal adult with functoning age of a preschooler develop depression, OCD and panic/anxiety attacks.

MAR, 31, 2016 12:42:05 PM
Becky Barnes
My daughter has had schizoaffective disorder with psychotic features for 23 years. Two and a half years ago she was fortunate enough to be able to move into a facility here in Minnesota that was designed by a psychiatrist and wellness-based social worker for people living with a mental illness as well as being medically fragile. The difference in my daughter has been phenomenal. She has her own apartment but assisted living services available, with 3 meals provided every day and an on-site nurse to make sure she takes her medication. With 39 other apartments in the building, there are always people around to eat with, play a game of cards, go for a walk, etc. The attached wellness center has exercise bikes, acupuncture, etc. They have a couple of vans and the activity assistant takes them on outings for movies, theatre, coffee houses, etc. My daughter's favorite is karaoke night! Living there has broken her cycle of being committed to the state hospital, losing housing, etc. It is the answer to this mother's 23 year long prayer and truly a dream come true.

MAR, 31, 2016 11:53:06 AM
Eugene Meyer
This type therapy has been available for years and is widely practiced in mental health facilities that offer group therapy. People who are interested should check into their local mental health centers and ask if they offer day treatment services and/or group therapy.

MAR, 31, 2016 11:34:22 AM
Paula Radke
Being part of a community, cures everything. I am also in San Luis Obispo Co.
Let's make it happen here! We have Transitions to help us make it happen.

MAR, 31, 2016 10:43:33 AM
Jorge Hernandez
Interesting therapy, please le me know where this therapy is provided. I had a 33 year son that is in urgently need and we are desperate to get help to him because we are old people and we are extremely concerned what will be of him in our absence. Please, HELP.

MAR, 31, 2016 09:47:24 AM
Robin
This approach is being used in Massachusetts's new mental health facility, the Recovery Center of Worcester. My son has been there for nine months with Schizoaffective Depressive Disorder, and the medication, the daily schedule of activities (including yoga, art, cbt therapy, "hanging out" in a "downtown" area with a coffee shop) has helped him to feel almost normal, alert, and hopeful, and has alleviated his depression. He is looking forward to moving out into the community soon!

MAR, 31, 2016 09:19:11 AM
c j buechler
The term "thought disorder" has stopped catastrophic thoughts in the worst physical/psychological seizure. It contributed to my skill of choosing a mood to feel and not taking pot luck. The value of intellectual discipline, either schooling or self-directed (computer programming) is astounding. Unfortunately stigma against the mentally ill, even in physically handicapped assistance is alive and well. No one is looking at the ease with which I direct and complexities of cyber life. The cast on my leg or the wheelchair are not quite as serious when I am online.

MAR, 31, 2016 08:35:56 AM
Sue
Do you answer the questions left? I too would like to know where my son can receive this treatment and get his life back. We live in NE Ohio.

MAR, 31, 2016 07:43:57 AM
Becki
Most of the comments are people asking for help, I feel there pain. There is no help for mental health, it is so sad. I love this information in this article, I totally believe that this is the help that is needed along with medication. As a parent of a 28 year old son with Schizoaffective Disorder this treatment would be a dream come true. Please email me any information.

MAR, 31, 2016 03:21:29 AM
Janette
I have long believed that my son who was diagnosed with schizophrenia would benefit from this type of therapy. His negative thinking began long before his illness surfaced. There is I believe a connection, but what doctor will listen? None. The healthcare system in California is dictated by the healthcare insurance providers and pharmaceutical companies, sadly!
Although the study is credible and coild help thesw patients live normal lives, no change will take place until our system stops health insurance and big pharma from.having absolute power
My son was/is a gentle, loving and brilliantly talented young man. This illness has brought his life to a screeching hault. My heart is broken and I cry for him daily
Even NAMI let me d.own when I needed them the most.

MAR, 31, 2016 01:41:23 AM
Leticia Paige
My son was diagnosed with schizoaffective at 31 and is currently in a mental rehab center. This is so interesting and I truly believe this is an avenue and opportunity all should have for recovery. Would you happen to know if this available to these types of facilities?

MAR, 31, 2016 01:03:08 AM
Margie LaRoche
Finally, some attention is being paid to the devastating effects of the NEGATIVE symptoms on the sufferer's life! It is about time! I am so pleased and relieved to read about these findings!

MAR, 31, 2016 12:56:13 AM
David Dominguez
Certainly there Is Hope for My daughter.

MAR, 31, 2016 12:19:24 AM
Camille S.
Will there be a follow-up article after Paul Grant speaks at the national Convention in July/

MAR, 30, 2016 10:32:52 PM
Patti Evans
I would love to get my son in a program like this. Unfortunately he's an adult and won't agree to any treatment of any kind. I feel so helpless.

MAR, 30, 2016 10:28:46 PM
Don
There is a wonderful outpatient adult program in San Diego from Sharp Health Care that has completely transformed my mother (with the help of medications and a hospitalization stay). The program runs 4 days a week. One of her favorite days is "Art Day" (Wednesday). They do arts & crafts. Another favorite is singing. Another big hit is when they (she is a senior) interact with the Teenage group; each group does something for the other like create a greeting card.

Medication is an important part of recovery, but without programs like this, my mother would not be nearly as healthy and well (free of most negative symptoms) as she is today.

MAR, 30, 2016 10:05:14 PM
Paulette wood
My son suffers from schizoeffective disorder.
I would like more information on this research and information on where I can find this type of treatment for my son.

MAR, 30, 2016 09:32:15 PM
Linda
I believe my son has schizoafwfective disorder. He does not have delusions but he has totally isolated himself in our home. He thinks negatively and refuses to see a doctor or seek any medical treatment. I think he could improve greatly with group therapy and social activities and acceptance. We live outside Philadelphia. Any suggestions? I do attend NAMI meetings.

MAR, 30, 2016 09:15:45 PM
Monica Benavides
Where can I find this type of therapy. My brother is 29 yrs old. Please let me know.

MAR, 30, 2016 08:54:41 PM
sandra Robbins
My schizophrenic son moved to west Philly, out on his own for the first time. So excited that a cutting edge facility like UPENN was nearby. Well that was a joke they wont take blue cross or united health care both if which he has, they only accept people who have their insurance into the cognitive therapy program. He hasn't found any resources in a city of 4 million people. I have called over 6 facilities.

MAR, 30, 2016 08:42:33 PM
Diane
Thank you

MAR, 30, 2016 08:40:41 PM
Diane
My son has been told he has schizophrenia then schizoeffect disorder. He has been in and out of different facilities, given medications that at times he becomes a zombie. No one has taken the time to properly diagnosis him....He just seems to get rubber stamped...He is a hopeful /half cup full kind of guy most of the time.....
He is on disability with Medicare, so there is no real help for him....I personally think he has neither of these..... I do know that at this point he has PTSD, depression at times, anxiety and since the first grade had ADD..
Is there any place in South Florida that he could be formally diagnosed? .
Our limited income has denied us a true diagnosis.
I'm a member of NAMI and am forever looking for help.
Thank you for all the good hope you bring to us.....

MAR, 30, 2016 08:29:14 PM
Ana
Great news...Research and Doctors who truly and really care make a difference...I live in South Carolina and wish my Son could have this type of treatment for Schizophrenia.. I hope this Dr can visit SC.. I wish I can attend the conference. It s not easy because of funds..

MAR, 30, 2016 08:07:39 PM
lisa tomlin
Majority of comments posted ask where to find this care and treatment....no such place seems to exist for my daughter in New Mexico...she is terminal and destined to have a life of struggle, hardship, such a waste of life. There is no meaningful long term facility...case worker outlined plan.. working the system...in and out of state hospital over many years until deemed unable to care for herself. Nothing available so no care as outlined in this article.

MAR, 30, 2016 07:08:18 PM
michele bishop
My son went into a pychosis in oct of 2014 he came out of it after about 9mon and was about 80 % back to normal till jan of 2016 then he had a pyhcodic break and totally lost all reality he was hospitalized for 17 days put on his 5th medicine and discharged until the medicine stops working yet again the doc says he has schzofrenic affective bipolar w phycosis but i dont know

MAR, 30, 2016 06:56:52 PM
fernando cajale
I want to help my son, he is high functioning schizophrenia, with negative symptoms .
where can I get an online course for him as we live in south florida where mental illness is still very
lacking in care. we believe in neuroplasticity as well , any ideas here?
thank you

MAR, 30, 2016 06:39:51 PM
Marie G
My son has schizo-affective disorder for the last 11 years. If only everyone who would like to improve their symptoms/illness would have that help available to them. Right at this moment he is appealing the decision to repeal his disability financial and medical assistance.That stress alone has worsened his disorder. I wish... I wish...

MAR, 30, 2016 06:33:38 PM
Jennifer
Since my daughter was diagnosed I have been extremely positive and helpful to help her get out of that funk. Her school district sets up ED Students with interviews and will pay their paychecks to give them experience and to boost their self esteem and confidence. Hopefully this continues into her adulthood with others around her. Negativity does pull her back down. With positivity it does work with social capabilities.

MAR, 30, 2016 06:23:08 PM
Jenny
It's called Cognitive Behavioral Therapy (CBT) guys. Just one of many types of therapy. You can call therapists in your area and ask if they practice this type of therapy. I don't recommend going to a Kaiser Permanente for it though. KP's psychiatry department has been fined for its poor patient care. I improved just by reading the book "Feeling Good: The new mood therapy" by David Burns which is all about CBT.

MAR, 25, 2016 03:14:18 PM
Christa stefoni
Are there programs of this type on the California central coast near San Luis obispo, CA?

MAR, 25, 2016 01:19:35 PM
senthil kumar
Very interesting, and absolutely supports recovery. Scheduling the day with interesting activities and motivation to do the same helps fast recovery. Great work sir. All the best.

MAR, 24, 2016 10:38:57 PM
micky
Where is this facility? I am looking for a in house facilty, short term to help guide my boyfriends sonn.

MAR, 21, 2016 09:35:14 PM
Marc
How does one access this type of therapy?

MAR, 20, 2016 11:46:16 AM
Jim Del Monaco
Hello,
I can not believe it took only two "caring" doctors, in the vast field of mental health professionals, to decide to look outside the box for another approach to treatment. I too suffer from a form of mental illness...ADHD/Depression. It runs throughout parts of my family. It has caused a great deal of pain, compounded illnesses, financial loss and death. The lack of good/correct information reaching the patient is extremely difficult. More importantly, the current establishment and it's professionals are not willing to change their approach to treatment. I was lucky though, but not timely, in finding a doctor who was thinking outside the box! His name is Dr. Ned Hallowell, and he saved my life. More importantly, he allowed me to use the knowledge I acquired to raise my son (also dealing with ADHD/Depression) with love and commitment. It was a strength based approach and identical to what Dr. Beck and Dr. Grant exposed: "CONNECT, PLAY, PRACTICE, MASTERY, RECOGNITION". There are other pieces, such as nutrition and medication, that have aided in our treatment plans.
Sincerely,
Jim

MAR, 18, 2016 09:32:46 AM
Carolyn
Where can adults with mental illness find activities during the day time?

MAR, 18, 2016 09:22:39 AM
maureen donovan
Ah yes very positive .....now the trick to present to each states Dept of Mental Health,their state hospitals, surrounding communities,and residential settings,acute psychriayeic hospital settings, outpatient settings,and insurance companies....a tall order this...hopeful

MAR, 18, 2016 07:28:39 AM
Pat Beck
Are you saying that being active, getting involved, is more affective than taking medication ( drugs)?

MAR, 18, 2016 01:47:14 AM
MaryAnn Drennen
I wish my son would get this help it seem like lincoln county oregon just won't help him.theyou need people like this to help them .

MAR, 18, 2016 01:40:33 AM
Jody
I was diagnosed with schizoaffective disorder. I don't have hallucinations or delusions, but a lot of the article resonated with me. Where can I get this kind of treatment? Please contact me privately.

MAR, 18, 2016 01:16:26 AM
Angela Rich
informative

MAR, 18, 2016 01:04:37 AM
Walter Smith
Great research

MAR, 17, 2016 10:55:57 PM
lisa Peters
I would like to know if you will ever be in the prescott az area?
I have DID dissociation Identity disorder. I'm currently a client of SWBH in Prescott valley and I really want help with my disability.
It seems not to many people,,facilitators, my probation officer, the mental health court judge, or even the the director of SWBH, AND or risk management there either.
I am the only one there diagnosed with DID but not getting any help for that however I've been a full time client of the day program for 6 months and have healed tremendously from many other problems but I still long to find help with this.
Will you plz help me get in touch with someone who can help me?
Thank you for your time,
Best Regards,
Lisa, "DID"; ((

MAR, 17, 2016 09:52:02 PM
Jolan Smith
I have a son who suffers from the negative symptoms of Schizoeffective Depressive Disorder. I have believed for the last year that there should be a treatment available to change his negative thinking. Every time a little bit negativity slipped away, his entire personality changed.

We live north of Pittsburgh, Pennsylvania and are desperately searching for the appropriate treatment for my son. I believe that the above treatment plan would make 100% difference in his life, giving him back a life.

Please if anybody has advice for a great treatment program, any assistance would be greatly appreciated!!

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