The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

The Promise of Today’s Cognitive Behavioral Therapy for Recovery

Elizabeth Saenger, PhD

In Cognitive Therapy for Beginners and Thieves, star clinician and educator Judith Beck, PhD, notes that regardless of our level of expertise, or theoretical orientation, many of us use techniques from cognitive therapy (aka cognitive behavior therapy, or CBT). This is not surprising, given that CBT is supported by more than 1,000 outcome studies.

However, we tend to restrict ourselves to CBT for depression and anxiety, two areas CBT addressed in its infancy. We thus miss applications of the treatment which experts have developed over the last thirty years to treat an empire of specific symptoms, disorders, and issues.

This new territory includes challenges faced by many clients, such as:

• Hallucinations and Delusions. Unlike most therapies, which define voices as hallucinations, and the client as mentally ill, CBT for psychosis focuses on understanding what the client believes about the voices. Are they external? Omniscient? How do they make the client feel? If abusive voices make people anxious, how can clients reduce their anxiety? And what precipitates the voices? If trauma triggers voices, therapy explores that trauma. Similarly, the goal in addressing delusions is to explore the client’s understanding of them, jointly examine whatever self-defeating behaviors might stem from those dysfunctional beliefs, and consider changing them.
   
• Sleep.  CBT for sleep disturbances might begin with having the client keep a detailed sleep diary for a week or two. Based on that, clients might try one or more techniques, such as:
  
  
• Stimulus control therapy: going to bed, and getting up at the same time every day; leaving the bedroom after twenty minutes if still awake; forgoing naps; and generally strengthening the association between going to bed and going to sleep.
  
  
• Sleep hygiene: lifestyle changes, such as giving up coffee at dinner.
  
  
• Sleep restriction (more appropriately called bed restriction): decreasing the time spent lazing in bed. This technique can cause sleep deprivation. Sleep deprivation can result in fatigue the next night, which can lead to better sleep. 

People with bipolar disorder or schizophrenia are at risk for a variety of sleep problems, particularly insomnia. Normalizing these sleep problems is associated with improved client outcomes. Therefore, it is encouraging that the few small studies of CBT for sleep disturbances with people with mental health diagnoses show benefits.

Before trying these techniques with your clients, however, you should read the fine print.  Sleep deprivation from sleep restriction can precipitate mania in clients with bipolar disorder if not handled appropriately.

• Adherence to Medication for Schizophrenia. Standard psychoeducation for people with schizophrenia focuses on teaching clients about their disorder, symptoms, and need for antipsychotics, all within the medical model. However, this approach backfires for patients who reject the diagnostic label they have been given.   
  
  CBT for adherence to medication avoids clashes over whether schizophrenia is a brain disorder, and whether patients have an illness. Instead, the therapist starts with patient-focused care that identifies people’s goals, and stays with their agenda. The therapist listens to what bothers the person, and regards patient communications about medications—even if they are complaints—as a good sign. Paradoxically, patients who received CBT for adherence voice more complaints about their medication than those in a control group, even though they are more likely to take the medication.
  
  Why does CBT for adherence work?  Probably the therapeutic qualities named above lead to great satisfaction with care, and research shows that satisfaction with care and confidence in the doctor are associated with increased adherence.  Relationships in general support adherence, explaining why, for example, married people follow treatment regimens more than single people. 

In short, CBT has expanded further into the province of recovery, where it has taken root, borne fruit, and promises a plentiful harvest.

Five Tips for Becoming a CBT Champion for Clients in Recovery

Elizabeth Saenger, PhD

Mark Twain said, “When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years.”

Similarly, when I first heard about CBT, I thought it sounded like the common sense my mother used with me when I was a teenager. However, by the time I became a psychologist, I had respect for the wisdom in this evidence-based paradigm.

With age came an appreciation of how generic elements of CBT could be tailored to a variety of individuals:

•  Ask the critical question often. "What were you thinking?" will enable you to uncover automatic thoughts when a client reports a feeling. Why did the client have a micromomentary flash of sadness when he told you about attending a Hearing Voices group? What prompted anger in your client’s account of visiting her mother? Excavate!
  
  
• Use the triple-column technique to explore distorted thinking.  We frequently use CBT for simple cognitive restructuring, and stop at that. But you might want to try the triple-column technique, which is a little more structured, and uses paper and pencil.
  

Examine irrational thoughts by having the client list the situation in the first column, the client’s distorted interpretation of the situation in the second column, and alternative interpretations in the third column. Have your client estimate how likely these interpretations are. Discuss them. This technique helps people rationally evaluate the evidence against negative thoughts. 

• Conduct a behavioral experiment. If your client has an irrational belief, jointly find a way to test it so he can reject the misconception if it proves unfounded.
  
  
• Help your clients benefit most from treatment. Many clients, especially those who have had protracted periods of psychosis, suffer from cognitive deficits. Ask clients to summarize the current discussion, or the session of the previous week, so you can see how much they have retained. Suggest they bring a list of concerns to sessions so they will not leave out something which matters. Invite clients to take notes during session. Give them handouts to reinforce key points, and enable them to refresh their skills long after therapy has ended.
  

• Put yourself out of business. The goal of CBT is to teach clients to identify and correct distorted thinking, master their anxiety and panic, improve their sleep, and so on. In short, CBT exists to help clients cope with their problems. Success means losing a client who has become his own therapist.

  
  

  
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The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.

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