November 2009  << Back  

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Back to Life, Back to Normality. Cognitive Therapy, Recovery and Psychosis

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Douglas Turkington, David Kingdon, Shanaya Rathod, Sarah K. J. Wilcock, Alison Brabban, Paul Cromarty, Robert Dudley, Richard Gray, Jeremy Pelton, Ron Siddle, and Peter Weiden; Cambridge University Press; New York, New York; 2009; ISBN: 978-0-521-69956-3; pp 186; $24.99 (paperback).

Cognitive-behavioral therapy (CBT) seems to be a treatment du jour lately. It almost reached the level of “psychotherapeutic aspirin.” I have seen books on using CBT for almost anything. The latest addition is this small volume on using CBT in psychosis and in the process of recovery from psychosis. It was written by a group of CBT experts from the United Kingdom (with the exception of one schizophrenia expert in the Introduction). They all wrote a chapter and are listed as authors of this book. The book also includes a Foreword and a cover endorsement by the father of CBT, Aaron Beck. Dr. Beck writes that, “access to CBT by people suffering from psychosis is limited largely due to a shortage of suitably trained therapists. Now, this current volume by Turkington and colleagues attempts to bridge this gap by providing guidance on self-management of psychosis” (p vii). According to Dr. Beck and the book’s authors, this volume is written for sufferers and carers, friends, families, and mental health professionals in training.

After the Foreword, Acknowledgements, and Introduction, the book consists of 9 chapters. The Introduction attempts to answer various basic questions, such as “What is psychosis?”; “What is recovery?”; “Why have we written this book?”; “Why write this book now?”; “Why CBT for severe mental disorders?”; “Who is this book for exactly?”; The authors also let us know that, “Psychiatrists are not hostile to the idea of patients and carers being guided through CBT.” They suggest that by using CBT, “Nerves and sadness, which are almost always present in a severe nervous breakdown, can improve” (p 5). Another great “subliminal” message is that CBT is “a safe treatment, which does not lead to suicide or any dangerous side effects” (p 5). In spite of these statements, the Introduction is one of the better and more informative parts of this slender volume.

The first chapter, “Where do I begin? (…or so many problems, so little time),” aims “to offer the reader guidance in how to begin the process of understanding what is wrong with them” (p 11). It is a mixed bag of personal examples, instructions for using diaries to record symptoms, functioning, and creating the timeline of life events or key events surrounding a recent episode of psychosis. The following chapter, “What is normal?” is supposed to be an antidote to stigma (p 23). It attempts to explain that many psychotic symptoms can occur to anybody, and also tries to define normal thoughts and beliefs, voices, and paranoia “in the normal population.” I admit that I failed to see what normal really is, even after reading this chapter twice. Chapter 3, “Understanding paranoia and unusual beliefs,” discusses issues such as paranoia as a normal experience, how common paranoid thinking is, the down side of paranoia, and making sense of paranoia, and suggests that it may be useful to view paranoia in terms of phobic anxiety. The authors propose that cognitive-behavioral techniques may help to better understand paranoia and that some home exercises may reduce distress and isolation. I am not sure if a schizophrenic patient would find it useful to know how common paranoia is, and I am curious to know how many severely mentally ill will read a chapter like this. The following chapter, “Voices,” focuses on helping the reader understand auditory and other hallucinations, and helping the patient cope with them. The final chapter that is focused on symptomatology, “Overcoming negative symptoms,” aims to help the reader understand negative symptomatology and again attempts to provide strategies for coping with and lifting this symptomatology. One wonders whether these strategies were tested in solid studies (the listed references do not provide this information).

Chapter 6, “Tablets and injections,” offers “an understanding of the role of antipsychotic medicines in facilitating recovery and preventing relapse.” The list of antipsychotics is incomplete for a reader in the United States, as it reflects the United Kingdom armamentarium—eg, it lists flupenthixol decanoate and zuclopenthixol decanoate, but not haloperidol decanoate. I am also not sure whether it makes sense to explain to patients how these medications work when we do not know. The chapter also contains a table rating the effectiveness of various antipsychotics. As in the other instances, the source of this rating is not apparent, and the rating seems a bit subjective.

The last 3 chapters discuss issues such as understanding vulnerability from a cognitive perspective (chapter 7), helping carers help themselves using a cognitive approach (chapter 8), and preventing relapse and staying well (chapter 9). The chapter on relapse prevention is probably the most useful in the entire book. It discusses how common setbacks are and what causes them (eg, stopping medication, abusing substances, missing sleep, or meals). It provides a list of “high-risk times,” early warning signs, and a plan for “how to stay well.”

I am a bit skeptical about this book’s utility. First, I am not clear on the book’s goal and audience. Dr. Beck and the authors suggest that almost everybody is the intended audience. Yet I have a hard time imagining that patients suffering from a psychotic disorder would buy and use this book. Second, many of the assertions presented in this volume do not seem to be backed by solid data. Third, the writing and editing of this text is rather poor (I provided some examples). The authors could have considered using one solid, common case presentation throughout the book, meaning discussing the same patient in the chapter focused on paranoia, voices, negative symptoms, treatment, and prevention of relapse. Fourth, the book is written with a United Kingdom perspective. There is nothing wrong with that perspective, however, it may not be applicable to US clinicians. Last but not least, Dr. Beck’s Foreword and endorsement is nice, yet almost borders on a conflict of interest.

I represent the psychiatrists mentioned in the Introduction to this book—I am not hostile to the idea of patients with severe mental illness and their carers being guided through CBT. I believe that CBT could be useful for severely mentally ill patients, and anything that can help and not harm our patients should be used and applied. I do not believe that this book provides readers with the best guidance for CBT in the severely mentally ill. Unfortunately, this book fails to meet its goals.