People Recover

Treatment is effective

Prevention works

Behavorial Health is Essential To Health

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Recovery-Oriented Cognitive Therapy:

Theory, Evidence, and Activating the

Adaptive Mode

Paul M. Grant, Ph.D. & Ellen Inverso, Psy.D.

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https://www.ncbi.nlm.nih.gov/pubmed/24079355

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https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107449

Background and Theory

Symptom, Side Effect, Secondary Diagnosis?N

egat

ive

Sym

pto

ms Decreased

emotional response

Decreased motivation

Reduction in socialization

Decreased speech and activity

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Of 7678 people diagnosed with schizophrenia• 41.0% had at least two “negative”

symptoms documented• Frequency:

Motivation 30.5% Affect 27.4% Eye contact 26.0% Emotional withdrawal 23.5%

South London and Maudsley NHS Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register

Cognitive Model: Beck’s Cognitive Triad

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Negative views about the world

Negative views about oneself

Negative views about the future

Everyone hates me because I’m worthless.

I am worthless.I’ll never be good at anything because everyone hates me.

Dobson, K. S., & Block, L. (1988). Historical and philosophical bases of cognitive behavioral theories. Handbook of Cognitive behavioral Therapies. Guilford Press, London.

Beliefs about self, other, and the world

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Cognitive Triad 1Self

2External

3Future

SymptomSituations

Task Orientation

I am broken, inadequate, and inefficient

The task is too demanding

I will failAmotivation, Avoidance

PleasureI am incapable of having pleasure

Nothing out there is enjoyable

I won’t enjoy the activity

Anhedonia: inability to feel pleasure

Inter-personal

I am unlikeableOther people aren’t friendly

If I socialize I will be rejected

Asociality, Avoidance

EnergyI don’t have energy

The demand is too energy depleting

I won’t have energy to do it

Anergia: abnormal lack of energy

Connection

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Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497-529.http://dx.doi.org/10.1037/0033-2909.117.3.497

Basic Science: Constructs

• Understanding mechanisms informed by cognitive model to drive treatment

• Measure development and validation

• Self esteem scale

• Cognitive insight scale

• Uncertainty tolerance

• Excitement interest scale

• Self concept scale

• Other validated measures: community participation, functional outcome, neurocognition, symptomatology, and beliefs (e.g., hopelessness, avoidance, flourishing)

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Studies

• Association (path analytic/structural equation modeling/regression)

• Cross sectional• Longitudinal

• Experimental

• Experience Sampling

• Samples: Chronic, ultra-high risk, early episode

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Defeatist Beliefs

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Neurocognitive Performance

Defeatist Beliefs

Negative Symptoms

-.32* .41**

-.24*

Taking even a small

risk is foolish

because the loss is

likely to be a disaster.

Meta-Analysis

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Timothy R. Campellone, Amy H. Sanchez, Ann M. KringSchizophr Bull. 2016 Nov; 42(6): 1343–1352. Published online 2016 Mar 15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049520/

Asocial Beliefs

“I prefer hobbies and leisure activities that do not involve other people.”

“People sometimes think I am shy when I really just want to be left alone.”

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THE EXISTENCE of multiple pathways to community participation in a longitudinal model supports the utility of multi-modal interventions for serious mental illness (i.e. treatment packages that build upon individuals' strengths while addressing the array of obstacles to recovery) that feature Unproductive attitudes and motivation as treatment targets.

From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation.

Thomas EC, Luther L, Zullo L, Beck AT, Grant PMhttps://www.ncbi.nlm.nih.gov/pubmed/27884217

Pathway Paper*

Defeatist Performance

BeliefsMotivation

Community Participation

Asocial Beliefs

MotivationCommunity Participation

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* From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation https://doi.org/10.1017/S0033291716003019

Self-Concept

Delusions

Motivation

Self-Concept

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Cross Sectional: Defeatist Beliefs Results

Baseline Defeatist

Beliefs

Neurocognitive Performance

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p < .01

Defeatist Beliefs and Neurocognitive Performance

Baseline Defeatist Beliefs

Change in Neurocognitive

Performance

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p = .04

Changes in Defeatist Beliefs from Baseline to

6 months

Changes in Neurocognitive

Performance from 6-12 months

p = .034

Cognitive Insight and Neurocognition

Baseline Cognitive Insight

Change in Neurocognitive

Performance from Baseline to Follow up

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p < .01

Changes in Cognitive Insight from 12 to 18

months

Changes in Neurocognitive

Performance from 18 to 24 months

p < .01

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Negative Symptoms

Effort

Defeatist Beliefs Poor

Performance

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Social exclusion

?

Mood

Stress

Self-defeating attitudes

Reduced effort

Avolition

Decline in global defeatist beliefs

Improvement in social functioning

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Decline in work-specific defeatist beliefs

Better social functioning, self-esteem, and work

behaviors

Mervis, J. E., Lysaker, P. H., Fiszdon, J. M., Bell, M. D., Chue, A. E., Pauls, C., ... & Choi, J. (2016). Addressing defeatist beliefs in work rehabilitation. Journal of Mental Health, 25(4), 366-371.

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Social ExclusionDefeatist Beliefs and

Poor Performance

Reddy, F., Reavis, E., Polon, N., Morales, J. & Green, M. (2017b) The Cognitive Costs of Social Exclusion in

Schizophrenia. Schizophrenia Bulletin 43, S54-S54.

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Validation:

Clinical Trial of CT-R

http://www.mentalhealthexcellence.org/wp-content/uploads/2013/10/2011_ArchivesGeneralPsychiatry_doi-10-1001-archgenpsychiatry-2011-129.pdf

Summary of CT-R Clinical Trial

Compared to people with Standard Treatment (ST) only,

people who received both Cognitive Therapy (CT) and

Standard Treatment (ST) had:

• Better functioning (d = 0.56)

• Reduced avolition-apathy (d = -0.66)

• Reduced positive [active] symptoms (d = -0.46)

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(Grant et al., 2014, Archives of General Psychiatry)

Clinical Trial Follow-Up

Gains maintained over the course of 6-month follow-up in which no therapy was delivered:

• Better Functioning (d = 0.53)

• Reduced Negative Symptoms (d = -0.60)

• Reduced Positive Symptoms (d = -1.36)

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Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals With Schizophrenia Grant, Bredmeier, Beck. https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201600413?af=R&

Clinical Trial Follow-Up

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NOTE: tp < .10, * p .05, ** p < .01

Mechanism of Therapy

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Importance of Positive Beliefs

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• 35 individuals with low neurocognitive scores and elevated negative symptoms

• Guided Success vs Control

• Changes in positive beliefs and mood most impact improvement in task performance

Translating Science to Practice

Access Energize Develop Actualize Strengthen

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Adaptive Mode

• Activating the adaptive mode• Ways to engage

• Beliefs increased

• Aspirations• Goals: valued, meaningful,

personal

• Meaning of accomplishing goal

• Obstacles• Current behaviors/obstacles

• Beliefs underlying obstacle

• Positive action• Current strategies and

interventions

• Symptom/behavior targeted

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Challenges to getting started

• Isolation

• Low energy

• Limited access to motivation

• Interpersonally lack of confidence

• Demoralized

• Hesitancy to connect and trust

• Really distressed

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When are people at their best?

• Birthday parties

• Big sports events like Super Bowl or NCAA Championship

• Picnics, gatherings with friends

• Movies or theater

• Listening to or playing music

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What do people look like at their best?

• Funny & Personable

• Knowledgeable

• Energized

• Warm

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Accessing the Adaptive Mode

• Shared interests• Talking• Doing

• What do we enjoy?

• What makes us happy?

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Accessing the adaptive mode

• Asking for advice• Problem solving

• I’m going to a potluck what should I make?• Binary questions

• This song or that song?• Curiosity about specific pockets of knowledge

• I’m trying to learn more about the sound of the city in the 60s – what should I know?

• Teach me…• About a specific skill set – dance move, recipes,

health tips

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Action Plan

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What do you want to try?1. _______________2. _______________3. _______________4. _______________

Questions DiscussionComments

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Thank you to our presenters

Paul Grant, PhDAaron T. Beck Psychopathology

Research Center

Ellen Inverso, PsyDDirector of Clinical Training

Beck Recovery Training Network

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SAMHSA’s

10 Principlesand

4 Dimensionsof Recovery in

Behavioral Health

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HomeHealth

CommunityPurpose

Recovery to Practice

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Through education, training,

and resources SAMHSA’s

Recovery to Practice (RTP)

program supports the

expansion and integration of

recovery-oriented behavioral

health care delivered in

multiple service settings

between multiple disciplines.

Want to continue your learning?

1Patel R, Jayatilleke N, Broadbent M, et al Negative symptoms in schizophrenia: a study in a large clinical sample of patients using a novel automated method BMJ Open 2015;5:e007619. http://bmjopen.bmj.com/content/5/9/e007619

2Rabinowitz J, Berardo CG, Bugarski-Kirola D, et al. Association of prominent positive and prominent negative symptoms and functional health, well-being, healthcare-related quality of life and family burden: A CATIE analysis. Schizophr Res 2013;150:339–42. http://dx.doi.org/10.1016/j.schres.2013.07.014

3Campellone TR, Sanchez AH, Kring AM. Defeatist performance beliefs, negative symptoms, and functional outcome in schizophrenia: a meta-analytic review. Schizophr Bull 2016;42:1343-52. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049520

4Peuskens, J., Demily, C., & Thibaut, F. (2005). Treatment of cognitive dysfunction in schizophrenia. Clinical Therapeutics, 27 Suppl A, S25-37. https://doi.org/10.1016/j.clinthera.2005.07.015

5Choi, KH, Jaekal, E. Lee, GY. (2016). Motivational and Behavioral Activation as an Adjunct to Psychiatric Rehabilitation for Mild to Moderate Negative Symptoms in Individuals with Schizophrenia. - PubMed -NCBI. Retrieved November 11, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27895602

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RTP Companion Newsletter on

Recovery-Oriented Cognitive Therapy

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Sign up to receive the RTP quarterly newsletter by visiting our webpage:https://www.samhsa.gov/recovery-to-practice

2018 RTP webinar Series: Recovery-Oriented Cognitive Therapy

Discovering Meaningful Aspirations and Taking Action#2 of 4 on Wednesday, January 17, 2018 1:00 pm to 2:00 pm ET

Remaining Dates:

Feb 7th and Feb 21st

Click here to register: https://ahpnet.adobeconnect.com/ekfeiy0nl7qt/event/event_info.html

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