Understanding Patients’ Motivations Through Cognitive Therapy Drives Breakthroughs

One key to getting mental health patients long mired in inactivity back to engaging in normal experiences is to start with a form of cognitive behavior therapy that doesn’t treat them as patients, Aaron T. Beck, MD, professor emeritus of psychiatry at the University of Pennsylvania and Judith S. Beck, PhD, president of the Beck Institute for Cognitive Behavior Therapy, told Evolution of Psychotherapy virtual attendees in a session presented on Thursday.

Dr. Aaron Beck shared an experience from the early 2000s in which he was approached by the commissioner of mental health in Philadelphia to serve on a panel on recovery orientation at the American Psychological Association. Through early research with a colleague, Beck found that mental health patients were more competent and capable than tests would have suggested. The key, he said, was implementing recovery-oriented cognitive therapy (CT-R) to identify patients’ motivations.

One patient, for example, believed he was Jesus Christ and frequently blessed those around him. Beck said a therapist asked the patient: What are the benefits of being Jesus? The patient said it allowed him to help others, which made him feel good. The therapist then took this motivation and worked with the patient to channel it into actionable items, in this case, collecting supplies for victims of a recent hurricane. Within a year, the patient was living independently.

“Over the course of time, he began to improve. It wasn’t as if that one experience snapped him out of his psychosis, but it was a really important start,” Dr. Judith Beck remarked. “What you had mentioned, too, was when the patient was in this adaptive mode, helping people, functioning and having normal human experiences, the delusion kind of went into the background and the staff never had to address the delusion directly.”

Dr. Aaron Beck shared another example in which a therapist who had been unable to engage in dialogue with a patient finally broke through by complimenting the patient’s fancy shoes. The patient then opened up about his interest in fashion. The therapist brought the patient to a local department store where he could meet with a buyer to further explore the potential for his motivation. The patient eventually was discharged and landed a job selling shoes.

“When we have a normal aspect, there’s a normal persona that is buried within a person. When this persona came out, he acted perfectly normally,” Dr. Aaron Beck said.

The progress made was a contrast to behavior observed at other periods in which medical students conducted status exams, Dr. Aaron Beck said. During those periods in which patients were treated in a more clinical manner, they reverted from a more connected and adaptive state back into their “disconnected patient” mode, he said.

A therapist at the Beck Institute had a similar breakthrough by focusing on a patient’s motivations instead of her delusions, Dr. Judith Beck said. The therapist in this case got a previously non-responsive patient to open up by providing a manicure. Other activities, from playing basketball to bringing in a pet or going out for coffee, can be similarly effective, she added.

“That’s the first step in: Figuring out how to engage patients who have been lying around and not doing very much, sometimes for decades, to get back to normal experiences,” she said.

Overall, CT-R has changed how Dr. Judith Beck has approached treatment in several ways, she said. First, it helps patients identify even small positive moments and draw adaptive positive conclusions about the meaning of those moments. Second, it helps to set goals that are aligned with patients’ values and then identify steps to achieve those goals and obstacles that can get in the way.

“The obstacles are probably the same obstacles that have been getting in the way,” she said. “They are practical problems that need to be solved, automatic thoughts that need to be responded to, and sometimes it’s a lack of skill and they need skills training. In addressing the obstacles, we use all of the regular CBT skills we’ve been using all along, but with the CTR orientation, we’re looking much more toward the future than the past and helping patients experience positive emotion right in the session and between sessions, and most of the session is oriented toward helping patients have a better week.”