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Introduction

Cognitive behavioral therapy (CBT) aims to change an individual’s distorted thinking to create positive thinking that results in more adaptive and positive behaviors. According to Brown (2012), CBT is especially effective for individuals experiencing hallucinations and delusions because of CBT’s focus on reducing distorted thinking. Using CBT strategies, one can reduce distorted thinking by identifying client negative thoughts and core beliefs, with the guidance of a therapist to facilitate more realistic ways of thinking.

Theory

Based on the cognitive behavioral theory, when changing negative thoughts, one’s behaviors can be positively affected. The therapist will challenge the client’s negative thoughts and provide him or her with insight and evidence to alter maladaptive thinking into adaptive thoughts (Brown, 2012). The objective is for the client’s negative ideas and thoughts to shift to a more realistic way of thinking, resulting in more positive outcomes in terms of behavior. This development of new positive thinking, in turn, increases different areas of engagement, including social participation.

Evidence

Evidence suggests that individuals with schizophrenia can benefit from CBT, as a review of meta-analyses found that it can produce favorable outcomes in the treatment of positive symptoms, such as hallucinations and delusions (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). There is also evidence that supports the use of CBT in addressing negative symptoms, although the effect was not as significant as with positive symptoms (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). In addition, researchers have found that CBT is an effective intervention approach in managing secondary issues associated with schizophrenia, such as mood (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness. Recently, Fitzroy has replaced his prescribed medication to manage his symptoms with a new homeopathic remedy he describes as being the “cure” for most ailments. Shortly following this change, Fitzroy has become confrontational and verbally aggressive with his roommates.  He has been observed yelling, swearing, and insulting other residents in The Fountain House, and will often storm out when upset.  Fitzroy was referred to an occupational therapist at The Fountain House to address medication adherence and his verbally aggressive behaviors.  The occupational therapist has already met with Fitzroy to conduct an initial session to define his problems, set goals, determine his readiness, educate about CBT, and assign homework.

Intervention Plan

Problem Statement

Fitzroy demonstrates distorted thinking about the treatments for his schizophrenia resulting in refusal to adhere to his prescribed medication schedule. His refusal to consume his medication is negatively affecting his ability to manage his symptoms.

Long Term Goals

1. Fitzroy will develop a pros and cons list when being prescribed a new medication independently in the natural environment to increase medication adherence within 4 months.
2. Fitzroy will be able to implement 2 adaptive strategies independently to monitor his negative and/or distorted thoughts to increase awareness to better adhere to medication within 4 months.

Short Term Goals

1. Fitzroy will identify 5 pros about taking his medications consistently during a therapy session with verbal cueing from the therapist to improve his medication adherence within 2 weeks.
2. Fitzroy will identify 1 possible consequence based on his viewpoint of not adhering to his medications to improve his medication adherence within 2 weeks.

Intervention Format

Individual session

Setting

Fitzroy will meet with the occupational therapist in an individual session at the Fountain House for 60 minutes 2x a week.

Supplies

None

Agenda

• Meet with Fitzroy & further develop rapport (5 min)
• Using CBT technique (25 minutes)
  • Feedback on homework assigned at prior session (diary writing)
  • Treatment decision making (pros and cons list about taking prescribed medications)
    • • Questioning: probe for assumptions and viewpoints
• Provide a summary of the session (5 min)
• Explain new homework (10 min)
• Client’s feedback about session (10 min)
• Discuss how client might handle his negative thoughts in the future (5 min)

Documentation

S: “This new medicine I have cures everything, even cancer.”

O: Client completed an hour session with occupational therapist using CBT techniques. Feedback was given on client’s homework assigned in the initial session (diary writing).  A pros and cons list was created about adherence to prescribed medication as a CBT treatment decision making strategy.  Client was provided with an informational sheet on his prescribed medication and, with verbal cues/probes from the therapist, identified 2 pros and 4 cons to using the prescribed medication. Therapist questioned client to explore viewpoints, identify evidence for his thoughts, and potential consequences to his behavior.  Client verbalized distrust in doctors and the benefits of prescribing his own medication during questioning and probing.

A: Client’s belief that physicians cannot be trusted and that he is able to effectively manage his symptoms using homeopathic alternatives, demonstrates distorted thinking and limited insight. Client demonstrated some improvement to insight during the session as he was able to identify 2 pros and 4 cons to using his prescribed medication. Client will benefit from continued occupational therapy to facilitate additional insight and address his distorted thinking.

P: Continue with CBT techniques for subsequent sessions to address distorted thinking. Target the client’s ability to identify negative and/or distorted thoughts presented in diary writing homework assignment, to assist in questioning clients’ assumptions, viewpoints and consequences of behavior. Client to see OT 2x/ weekly for 60 minutes each in session.

References

Brown, C. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: AOTA Press. ISBN-13: 978-1-56900-331-2

Hofmann, S., Asnaani, A., Vonk, I., Sawyer, A., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses.Cognitive Therapy and Research, 36(5), 427-440. doi:10.1007/s10608-012-9476-1