An electronic newsletter of the Coalition's Center for Rehabilitation and Recovery
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.
Abigail Strubel, MA, LCSW, CASAC
I met Jack in a dual diagnosis/re-entry program for parolees. All had fascinating stories about survival in prison (Got a little tinfoil? You can make a decent grilled cheese sandwich in a holding cell with a radiator). Most were symptomatic, because the policy was to take people off their medication as they neared release and were transferred to special barracks.
Jack told our admission coordinator his voices had advised him to skip intake. However, wary of returning upstate, he endured the appointment and met me. "I think I'll be able to work with you," he said. "You have intelligent eyes."
So did he, along with a glorious James Brown-esque pompadour. Jack was meticulous about his appearance. “Even when I was shooting ten bags of heroin a day, I made sure to shave, bathe, and wear clean clothes.”
"Ten bags a day?" I asked.
"Heroin makes the voices stop," he told me. "Better than any medication I ever tried."
Jack entered my office one day in a funk.
"I went to public assistance, and I know that lady's going to mess up my case," he said. "I could tell by how she looked at me. She made this face"—he pursed his lips and narrowed his eyes—"and the voices started saying, 'She hates you, she's not going to help you—she's going to get you all twisted.'"
"I wasn't there," I responded. "I don't know how she looked at you or what she thought. But there may be another way to interpret her expression—it could have been about something that happened before you even came into her office, or maybe she thought about something going on in her personal life.
"So the way she acted wasn't because of me?" he asked.
"Look," I said. "If you're right and she tries to mess with your case, you know I'll go to bat for you, make sure you get what you need. But it's possible something else was going on."
Jack nodded, then cocked his head to the side, listening. "The voices don't believe you," he said.
"Let me tell you about 'automatic thoughts,'" I said, and explained how almost everyone experiences a barely conscious stream of thoughts throughout the day. Some thoughts are positive, but many are negative. We can train people to become aware of their negative thoughts, and then dispute them.
"Your voices," I said, "are just a louder version of automatic thoughts. They're not real people; they're your own fears and doubts. When a voice says something negative, you can disagree. Ask, 'How likely is it that the welfare lady hated me on sight and wanted to make my life miserable? Could she have been having a bad day, and taking it out on me? If she did try to mess up my case, can my counselor help me straighten it out?'"
Jack thought that over. "You know," he said, "that makes a lot of sense. Because sometimes I can tell the voices are wrong right off the bat."
"And sometimes you might need to think about it a little more," I said, "or discuss it with me."
As treatment progressed, Jack's P/A case was resolved favorably, and he began contesting the negative voices on his own. Ultimately, he became a drug and alcohol counselor. His medications may never eradicate his voices, but now he knows how to dispute them.
Ms. Strubel is a clinical supervisor at Services for the Underserved/Palladia Comprehensive Treatment Institute-Bronx.
Elizabeth Saenger, PhD
Aaron Beck et al showed that cognitive therapy can promote clinically meaningful improvements in people with schizophrenia, even if they have significant cognitive impairment. That finding was published in Archives of General Psychiatry (now JAMA Psychiatry), America’s journal of record for the discipline. It surprised clinicians who thought of CBT as a treatment only for patients who were high-functioning.
But that discovery was three years ago. What have CBT researchers done for us lately?
Here are some advances from the last six months.
CBT as an Alternative to Drugs: A Proof-of-concept Study
When it comes to schizophrenia, the British seem to make a habit of upsetting the medical model. First they rejected auditory hallucinations as psychopathology, set up a hearing voices movement, and imported the concept to the US. Now researchers across the pond suggest in The Lancet: Psychiatry, the British journal of record, that CBT might get rid of persecutory delusions.
A small study focused on people with schizophrenia spectrum disorders. All had persecutory delusions, and had not taken antipsychotic drugs for at least six months. Researchers randomly assigned subjects to treatment as usual, or to a package of brief therapy including four CBT sessions focused on the subject’s specific delusions.
The goal of this package was to change people’s reasoning about their delusions. Investigators taught subjects to become more aware of their thinking processes, and to identify and inhibit jumping to conclusions. Researchers also encouraged subjects to be more analytical. These interventions increased subjects’ sense that they might be mistaken about their persecutory beliefs.
The results indicate that people were comfortable with therapy, and the intervention worked. Follow up data collected two months afterwards suggested the model was definitely useful.
Clinicians frequently use CBT as an adjunct to psychopharmacology for delusions, but they rarely use CBT alone. If further research confirms the results of this proof-of-concept study, perhaps people with schizophrenia will have more choices in the future. Given the common, generally unpleasant, side effects of antipsychotic drugs—such as weight gain, metabolic problems, movement disorders, and an increased risk of cardiac death—having a meaningful treatment choice in the journey toward recovery would be most welcome.
Merging CBT with Other Evidence-based Treatments
A recent tendency to mix and match evidence-based therapy has led to instances where CBT has been successfully merged with other psychosocial treatments. Here are three examples.
Social skills training. CBT material, such as that described above, can be presented using social skills training techniques, for example, waving a big flag in group to identify ("flag") beliefs that do not have evidence to support them. This treatment merger helps clients with cognitive and social deficits improve their negative (but not positive) symptoms, and is helpful for clients regardless of the severity of their cognitive impairments. Further, because the treatment is repetitive, new clients can join the group at any point.
Family psychoeducation. Data strongly show that CBT with family psychoeducation reduces stress, increases medication adherence, and decreases re-hospitalization. Modules are available that teach parents how to use CBT techniques with clients in recovery, and in other areas of their own lives.
Supported employment. CBT can help clients improve coping skills and challenge distorted beliefs about their vocational abilities. CBT is now being melded with supported employment to test the effectiveness of the combination. Preliminary results suggest people who received CBT in addition to supported employment might be more likely to work more hours per week.
The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.
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