CBT Found to Be Successful in Low-Functioning Patients

Cognitive-behavioral therapy (CBT) is a rigorous and proven approach to help with a wide range of mental disorders, but is it an approach that can work for everybody? Given the intensity of the sessions and the commitment involved in maintaining regular visits, it has been presumed that low-functioning patients would likely not benefit from CBT.

Paul Grant, Ph.D., an assistant professor of psychiatry at the University of Pennsylvania’s Perelman School of Medicine, didn’t think that this had to be case and that even patients with severe schizophrenia who were hindered by their psychoses and cognitive defects could be improved.

“The term I heard often for these people was ‘baseline,’ in that if their symptoms could be managed somewhat so they weren’t a danger to themselves or others, well, that was as good as it was going to get,” he told Psychiatric News.

“But I think clinicians sometimes forget there are people underneath all those symptoms,” he continued. “They’ve had very unfortunate experiences and have become socially withdrawn, but they can come out of their shells.”

At the time, Grant had been working on replicating British research that had found an effective CBT strategy for reducing hallucinations and delusions in people with schizophrenia, though these patients had been higher functioning.

Still, the framework was there, and Grant believed that adding elements of recovery-oriented care to the CBT could help achieve success.

“In carrying out interviews with these patients early on, it became clear that they didn’t lack the capacity to change; they just had a defeatist attitude that in a way mimicked what many doctors thought—‘This is as good as it gets,’ ” said Grant. The key to change that attitude, he explained, was to uncover the person behind the symptoms that made them withdrawn and paranoid.

Aaron Brinnen, Psy.D., a staff psychologist at Penn’s Aaron T. Beck Psychopathology Research Center and a colleague of Grant’s, discussed the strategies of recovery-oriented CBT (CBT-R) at APA’s IPS: The Mental Health Services Conference in October.

“The first step is to find a motivating connection,” he said at the session. “Find some of their pleasures and develop an interaction based on that. Focus on something that anyone would engage in, such as listening to music, cooking, or watching soap operas.

“Getting involved and making the discussion interactive is critical, whether it’s singing along with them or asking for recipe ideas,” Brinnen continued. “Use that rapport as a starting point to rekindle their internal fire and then start working with them on their recovery goals.”

Grant noted that these initial interview sessions were emphasized at the meeting since that aspect is the most common trouble spot with clinicians. “Typically, we use the first sessions to develop a therapeutic relationship, but in this instance it’s not so much about the relationship as using that connection to open up a vista for the patient so the patient can make progress.”

CBT-R focuses on treating negative symptoms such as lack of motivation and social withdrawal, but a driver of its strategy is to see positive symptoms as opportunities as opposed to obstacles.

“Frequently, the psychoses take the place of something else important in that patient’s life, and it provides a clue to what they need,” Grant said.

As an example, Grant mentioned one former patient who believed he was an extremely rich owner of a hospital, which Grant realized related to a desire to take care of things; having the patient take care of pets enabled him to realize his desires.

“That really seemed to help, and it illustrates that scale is not important for these patients, despite how grandiose their delusions may seem,” Grant said.He acknowledged that these grandiose delusions are another area that is seen as frustrating and off-putting to therapists.

“These delusions are exposing a need, and if you can fill that need with something tangible, even if the magnitude is small, we’ve seen that the positive symptoms do start to drop off.”

And while some clinicians might still be skeptical that discussing soap operas or giving a patient a goldfish are keys to recovery, Grant pointed out that in the decade or so CBT-R has been around, it has already demonstrated success in multiple settings including acute care, inpatient hospitals, and outpatient settings involved in assertive community treatment programs.

“Antipsychotics remain important tools, but I do think the value of some of these recent medications has been overstated, particularly in regard to the negative symptoms,” Grant told Psychiatric News. “It would be great if we could develop a pill that would motivate patients and get them back in the saddle, but until then CBT-R offers a way to address our gaps.”

At the IPS meeting, Grant discussed some recent data highlighting how a CBT-R regimen in the Pennsylvania state hospital system resulted in 72 percent of patients achieving an improvement in at least one clinical dimension of their schizophrenia (for example, positive, negative, cognitive).

And while the Philadelphia area remains a stronghold of this treatment paradigm, Grant noted that therapists have been trained in CBT-R throughout the East Coast, and new programs continue to spring up.

His team is looking at the forensic setting, a place that, tragically, all too many people with schizophrenia end up. While prisons do provide some legal hurdles in patient management, he believes the actual protocols would not need to be modified that much.

“The history of schizophrenia treatment has some dark moments,” Grant said. “Maybe I’m overly optimistic, but I think we are in a place now where professionals, especially younger psychiatrists, are seeing these patients in a different light.” ■