You could call CBT the Swiss army knife of talk therapy. Cognitive behavioral therapy (CBT) is as reliable and versatile as your multitool; and just when you think you know all the ways it can be used, someone discovers one more.
CBT is well known as a treatment for depression, anxiety, PTSD, obsessive-compulsive disorder and phobias; and perhaps less well-known, but certainly in use, for an eye-popping number of other mental conditions. It’s the #1 treatment for anxiety disorders, according to HelpGuide.org.
It's also used for physical problems, such as chronic pain, irritable bowel syndrome and insomnia.
CBT is abundantly backed by research, and it’s an insurance company darling because of its nice fit with “brief therapy.”
But, as the infomercials say: wait, there’s more! CBT can also be an effective treatment for psychosis.
Surprised? I was too – and I try keep a pretty good eye on mental health. But it’s true. In fact, CBT for psychosis –“CBTp” for short -- has so much research showing its value, it ranks as an Oregon-approved evidence-based practice.
There’s one drawback: it can be tough to find. There are only a handful of CBTp practitioners in Oregon – just nine in the entire state, according to Oregon’s Addictions and Mental Health Division.*
Ron Unger, LCSW is one of the few. He and others are working to spread the word and get more CBTp providers trained, but for now he is part of a rare breed – with a really great Swiss army knife.
Normalizing psychotic experiences
Unger’s Eugene-based practice focuses on CBTp, which he calls “a common-sense form of talk therapy” for persons with psychosis or schizophrenia.
How does it work? And what makes CBT for psychosis different from, say, CBT for depression?
“Cognitive therapy for psychosis is a well-researched approach to helping people who are having psychotic experiences, to reduce distress and to regain control over their lives,” Unger says.
“The most important part of cognitive therapy is called ‘normalizing,’ which means helping people make sense of psychotic experiences as meaningful and as variations of normal human response and functioning. This reduces fear of the experience, reduces ‘stigma,’ and helps people have insight into how to apply a variety of coping methods for their difficulties.
“The second most important method,” Unger adds, “is called ‘developing a formulation.’ This means putting together an individualized story or possible understanding of how difficulties developed and of how they currently manifest, which helps people make sense of how things have gotten bad and of how things might be turned around so as to go better.”
“A third key method,” he says, “is called ‘reality testing,’ which is a collaborative process of exploring beliefs and alternative ways of making sense, so that people can possibly find ways of making sense which work better in their lives and change their relationship with their experiences.”
Respect and curiosity
Unger’s approach isn’t the same one you might find in CBT for depression, where the therapist helps identify cognitive distortions (also called “thinking errors”), directly challenges the client’s “unrealistic” beliefs and encourages finding new, “better” ones. For a psychotic client, techniques pulled straight from the depression playbook could be useless – or worse. Instead, Unger says he takes care to incorporate respect and curiosity into the therapy, collaborating with the client rather than forcing a particular view of reality or the “right” explanation of the client’s experiences.
“As in the Open Dialogue approach,” he says, in CBTp “it is considered essential that cognitive therapists acknowledge their own uncertainty about what is going on and what might help. This allows for respectful and interesting relationships and dialogue with people having extreme or unusual states of mind, and also keeps an openness to the existence of possibly positive sides within experiences that are otherwise distressing.”
Therapy doesn’t end there – Unger's got a toolbox to share. “Cognitive therapists can suggest a number of specific coping ideas for various kinds of troublesome experiences, and can be good guides in overcoming obstacles in implementing those strategies,” Unger says.
And finally, “When recovery is well underway, cognitive therapy can be helpful in discovering ways to make further progress and ways to avoid ‘relapse.’”
Questions and answers
I asked Unger some questions about CBTp in general and his practice in particular. Here are his responses.
Q: Do you see much success in your practice -- and what constitutes success?
A: What I aim for is to help a person fully recover, which I think happens when they find a life that is meaningful to them, where they can relate well to others in areas like love and work, without needing drugs or other mental health treatments to keep that going.
But recovery is a journey that often takes years, and I typically see people for shorter periods than that, so I'm usually just helping people take some steps toward a possible recovery. I do frequently see people make very important progress, and I do sometimes hear back years later from people who report being able to build on that progress and basically accomplishing a full recovery.
Unfortunately, there are also times I can't seem to be helpful to people, or times when things spin out of control and go downhill while I'm trying to help without success. I wish I could work with something like an Open Dialogue team, where we had the resources to carry out as intensive an intervention as might be necessary in such cases, while staying with a humanistic and recovery oriented model.
Q: CBT is often used for the "brief therapy" that insurance companies may insist on. Do you practice brief therapy, and if so, how brief?
A: What I like about brief therapy models is that they try to provide real help as quickly as possible, so I do try to make my therapy a brief as I can while still meeting the person's needs! But I don't believe in denying more therapy when I can't manage to meet those needs quickly, so I do work with insurance companies to see people much longer-term, even for years, when that seems to make sense.
Typically, CBT for psychosis is offered for something like 12 to 30 sessions, and I do think that work during the earlier sessions is often the most productive. But when people have a lot of needs for assistance, I think it makes sense to offer long-term help as well. I also prefer to get people engaged with peers, in something like a Hearing Voices group, so they can help each other over that longer term, but not everyone can be persuaded to try that route.
Q: In your years as a therapist, what is the most surprising or significant thing you have learned?
A: I think the very most astonishing thing is the way the voices or parts of the person that at one point were trying to put down, harm, or even kill the person can later become a powerful friend or ally. The amazing thing about "mad" experiences is their ambiguity, the way they can often contain both something very bad, and something possibly very good. I'm always being challenged to keep an open mind, and to learn ways to help people fight against being overcome by the negative side of voices and other mad experiences, while keeping enough of an open mind that they can also find value in those experiences and eventually heal their relationship with them.
A rare breed – for now
Way back in 1979, Aaron Beck’s seminal Cognitive Therapy of Depression hit the shelves, and therapists jumped on the radical new approach to treatment that would beget CBT, and later, CBTp. At the time the book was published, though, Beck had no way to foresee the number of applications his ideas would eventually have, nor the extent of their usefulness in treating psychosis. Although his book did include a small section on cognitive therapy in psychotic depression, it was mostly hypothesis and hope, and almost entirely concerned with getting people to take their medications.
Fast-forward to 2014. CBT and CBTp have been studied exhaustively and have accumulated evidence in their support. Yet CBTp has been slow to catch on in the U.S., where biological psychiatry has a huge political and popular advantage, and the party-line mythology of schizophrenia and psychosis -- “medication is the one, only, and required treatment” – is so well-embedded into our culture, it might as well be an article of faith.
But even in the U.K., where often there is greater acceptance of novel practices -- such as Hearing Voices groups -- CBTp has to battle for acceptance. Stacks of evidence notwithstanding, Unger says “estimates are that [in the U.K.] only 1 in 10 people who could benefit are offered CBTp.”
On a hopeful note, he adds, “There are efforts to overcome [the scarcity of CBTp in the U.S.] For example, Doug Turkington, one of the leaders from the U.K., [just did] a week-long training in California, in an effort to make CBTp more widespread in that state.”
Unger’s doing his part as well. On his website you’ll find an upcoming online conference, several live seminars scheduled for this fall and winter in Eugene, and recorded webinars taught by Unger and others.
And hopefully, one day soon, he won't be such a rare breed.
*Note: The chart showing nine practitioners has been removed, so I've removed the link in the text. The information was current on AMH's website as of earlier this month.
Find out more
This is a big topic, and there’s loads of information on the Web -- but due to space limitations, most of it didn’t make it into the article. Here are just a few places you can visit for more information.
CBT in general
- NIMH: Psychotherapies
- Beck Institute: What is Cognitive Behavior Therapy?
- Psych Central: About Cognitive Psychotherapy
CBT for psychosis
- Ron Unger’s website – Highly recommended!
- “The Evolution of Cognitive Behavior Therapy for Schizophrenia: Current Practice and Recent Developments”; Sara Tai and Douglas Turkington; Schizophrenia Bulletin, 35:5
- “Evidence-Based Psychotherapy for Schizophrenia, 2011 Update”; Faith B. Dickerson, Ph.D., M.P.H. and Anthony F. Lehman, M.D., M.S.P.H.; Journal of Nervous and Mental Disease, 99:520–526
Ron Unger, LCSW
Postal Address: 1257 High St., Suite 7, Eugene OR 97401