The “Cognitive” in CT-R

When we enter a unit for the first time we notice that the people are relatively inactive. One person may be sitting in the corner hallucinating, another is fine on the couch, and the third person may be haranguing the nurses regarding medication. So we start to apply our Recovery Oriented Cognitive Therapy and low and behold, in the course of time, the individuals start playing the piano, singing, and dancing, decorating the unit and forming clubs. The question is: how does our program galvanize them into action? We apply our formulation, recovery plan, aspirations and find the sweet spot of interest in each individual, but how does all this translate into clinical improvement? Thus, we get to the reason for calling this Cognitive Therapy. Indeed, while we focus on activity and especially positive experiences, our ultimate aim is to change the negative beliefs and expectancies through these therapeutic experiences.

In a previous memo, I outlined the various dysfunctional negative beliefs that drive the negative symptoms. According to our theory, when these beliefs are deactivated, more positive and adaptive beliefs are activated. The activation of these beliefs thus provides the motivation and the energy to overcome the inertia and get back into real life. Of course with this transition there is a progressive movement towards recovering the adaptive mode: being realistic, pragmatic, solving problems, being resilient, etc.

What is the experimental evidence that cognitive change is responsible for the clinical improvement? Our work with non-psychotic patients demonstrated that cognitive change mediated clinical improvement. I believe that this was also demonstrated in the RCT of patients with psychosis by Grant et al. So the take-home message is: aim the program at producing changes in the individual’s beliefs about themselves, the outside world, and their future.