Recovery-Oriented Cognitive Therapy (CT-R) was originally developed by the Beck Institute to promote recovery and resiliency in individuals with a diagnosis of schizophrenia, but it can be applied broadly to individuals with various challenges. The Beck Institute describes CT-R as “highly collaborative, person-centered, and strengths-based and focuses on developing and strengthening positive beliefs of purpose, hope, efficacy, empowerment and belonging” (Beck Institute, 2021)1, making it a great treatment option for our facility where we have a percentage of patients with treatment refractory illnesses who have had poor response to traditional treatments. CT-R is a treatment that centers around recovery.
CT-R starts with connecting with the individual to identify a point in their life when they were doing better. This could be done by connecting them to an interest they had at the time. For example, music they enjoyed listening or even dancing to, cooking a meal, playing a sport, etc. Once the interest is identified, therapist and individual work together to explore their feelings and identify the meaning or value behind this feeling. CT-R aims to help the person identify their aspiration such as to feel connected, helpful, capable, and/or more energized. When in this adaptive mode, treatment focuses on finding ways to build and strengthen connection and motivation through repeating these activities and exploring the meanings behind them to link the meaning to the action.
What Is It?
CT-R utilizes a Recovery Map which can serve as a guide for treatment (Beck Institute, 2021)2. Individuals and therapists can work collaboratively to complete. Recovery Maps start with identifying interests and ways to engage the person as well as the beliefs that are triggered when they are active. They will identify goals and aspirations, how it would feel to accomplish these goals, and the meaning behind them. Maps also identify challenges that may interfere with accomplishing these goals. These challenges can be behavioral or the beliefs they hold about themselves. The last step is to identify strategies to create positive actions, finding purpose and building resilience.
As CT-R is recovery based and centered on the participant’s input and interests it also allows for a multi-disciplinary approach. The participant may connect with a specific therapy aide or a night shift nurse that they open up to or who observes them when they are most activated. Using this team approach and implementing CT-R within the milieu increases the chances for initial engagement and maintenance over time.
How Is It Done at SBPC?
In 2018 the NYS Office of Mental Health (OMH) selected South Beach Psychiatric Center (SBPC) to pilot CT-R. SBPC is a New York State OMH facility in Staten Island, NY that provides intermediate level inpatient and outpatient services to adults and adolescents with severe and persistent mental illness living in western Brooklyn and Staten Island.
Staff at SBPC completed initial training in person with the Beck Institute and then continued with bi-weekly meetings with Beck Institute consultants to review cases and get guidance for implementing the treatment. The treatment was piloted on 2 inpatient units, the inpatient day program, and the outpatient transitional living residence. In 2021 the facility did a new training to expand to staff representing the other inpatient and outpatient units to help implement the treatment facility wide. Outcome measures are taken using an instrument developed within the OMH system called the Indicators of Participation Scale [IPS]. Staff are asked to rate the participants from the time of recovery map development and at 3-month time points. The IPS is a general measure of activity to see if the participant is increasing connection with treatment. When a participant is ready for discharge and is being referred to one of our own outpatient programs we hold a meeting to share information about this person and what was effective/ineffective with the outpatient team to continue their progress using the CT-R model for treatment.
Initially, clinicians targeted participants who have shown treatment resistance to medication and/or therapy interventions with longer lengths of stay. Once identified, specific cases were presented during team consultations. Through consultation, recovery maps were completed to help guide the treatment along the CT-R model. From the map, we initiated participant specific activities.
One woman had an interest in crocheting. Staff began by allowing her to show them how to crochet, giving her the role as teacher and expert. This grew into a group with several peers and staff learning to crochet on a regular basis. Another woman had an interest in baking. She struggled with connecting with staff and peers. Staff worked with her and were able to identify some recipes she liked. She worked with staff to bake cookies, again becoming the teacher and the expert by showing the staff how to follow the recipe. She was then able to take this further by contributing to a facility bake sale. She volunteered to help and was able to hear the compliments about her cookies.
One participant was difficult to engage in both inpatient and outpatient units. Outpatient staff learned that he had an interest in music and wanted to get a cell phone. After showing him how to use the phone and access YouTube he started to share more about his history of going to raves and rave music. He has shown significant improvement, starting to connect more socially by showing others the videos he is watching and interested in and agreeing to attend community trips with the residential staff which he had not previously participated in.
Another participant was very quiet, did not interact socially, and needed a lot of encouragement to remain compliant with medication. Through brief and friendly interactions with staff and offering him coffee he eventually shared that he is a strict vegan and couldn’t drink it with milk. He has since been offered black coffee and accepted it and has been willing to engage in brief conversations with staff, sharing more about his decision to be a vegan and recently sharing that he would be interested in bowling. The residence is now planning a trip for the group to go bowling.
Another participant shared an aspiration of becoming a famous football player. Staff worked with him to ask more questions and understand the beliefs of his aspiration. The meaning behind wanting to be a part of a team was to feel like he belonged as he had no family connections at that time. Additionally, he wanted the respect and the recognition of others- connecting to his wanting to be famous.
In our CT-R group, participants would take turns as the group “barista” helping to make coffee or hot chocolate for group members as the group had identified that some caffeine, or at least a hot beverage, would be energizing and activating for them. This led to group members sharing memories associated with coffee or hot cocoa (ex- Grandma making hot cocoa on a snowy day) and building connections amongst the group members. Other ways we have engaged participants to be active include throwing a football or frisbee out in the courtyard and selecting a song to listen to/play the music video for and get participants to dance along.
If treatment-oriented care does not lead to recovery, the two can be integrated into a recovery-based treatment model such as CT-R. CT-R can be adapted to both inpatient and outpatient settings. It is not diagnosis specific and therefore can be broadly applied to a variety of people. One of the benefits of this treatment is that it permits participants to be the guide and direct treatment to recovery based on their own interests and values.
The next step for our and other OMH facilities will be to include more staff as The Beck Institute implements their next training initiatives. Continued consultations with Beck Institute will focus on more in-depth exploration of how to apply CT-R. Lastly, another initiative is a “Train the Trainer” program with the Beck Institute for the goal of making CT-R internally self-sustainable within the facility.
For more information about South Beach Psychiatric Center, visit omh.ny.gov/omhweb/facilities/sbpc.
Beck Institute. (2021). Recovery Map “How-To” Guide
Beck Institute. (2021). What Is Recovery-Oriented Cognitive Therapy? https://beckinstitute.org/center-for-ct-r/