CT-R recovery-oriented cognitive therapy

Recovery-Oriented Cognitive Behavioral Therapy (CT-R) is a modern, empirically-supported approach to working with people with serious mental disorders who have traditionally been considered difficult to engage in treatment. The method focuses on uncovering and enhancing the patient’s “adaptive mode,” aspirations and building mental resilience, rather than simply reducing symptoms.

Learn more about this working method and its effectiveness.

Key tenets of CT-R

CT-R was developed by Beck and Grant’s team as an extension of cognitive-behavioral therapy for people with very low functioning, lack of motivation and difficulty making connections. Research confirms that CT-R improves social and occupational functioning, reduces negative and positive symptoms, increases treatment motivation and quality of life, and the effects persist even after active therapy ends.

CT-R is based on Beck’s cognitive model, but specifically develops it in a recovery-oriented direction. The main assumptions are

• Every person, even those with severe mental disorders, has an “adaptive mode” – a state in which he or she is at his or her most energetic, motivated, engaged and connected with others.

• The goal of therapy is not only to reduce symptoms, but more importantly to discover, strengthen and expand this mode to become the dominant way of functioning.

• CT-R treats the patient as a person with potential, dreams and value, not just as a “disease carrier.“

• The therapy focuses on building a sense of connection, hope, life purpose and mental resilience, which is crucial for long-term recovery.

Four key elements of CT-R health-oriented cognitive therapy

CT-R is structurally based on four interrelated elements:

1. Accessing and energizing the adaptive mode

The first step is to discover what activates a person’s adaptive mode. This can be

• favorite music, movie, book, sport, hobby,

• memories of the past,

• talking about topics that are important to the patient (e.g., family, animals, travel).

The therapist looks for “hooks” – topics or activities that elicit a positive response, more energy and engagement. Techniques include

• short, frequent and predictable interactions (e.g., daily conversation about a favorite topic),

• asking the patient for advice or opinion (e.g., “How would you solve this?”),

• doing enjoyable activities together (e.g., taking a walk, listening to music, cooking),

• using media (music, movies, photos),

• playing activity games (e.g., simple board games, quizzes).

The key is for the therapist to be patient and try different approaches until he finds what works best for the patient

2. Developing aspirations and dreams

Once the patient is in adaptive mode, the therapist supports him or her in discovering and developing life aspirations. These may include dreams about

• work, studies, profession,

• relationships (partner, friends, family),

• hobbies, passions, helping others,

• living in the community, independence, travel.

Techniques for developing aspirations:

• asking open-ended questions about dreams and goals (e.g., “What would your ideal day look like?”, “What would you like to do if not for illness?”),

• creating rich mental images of the future (e.g., “Describe what your day would look like if you worked as [X]?”),

• discovering the deeper meaning and values behind aspirations (e.g., “Why is this important to you?”, “What does this say about you?”),

• enhancing hope and optimism about the future (e.g., “What indicates that this is possible, even if it seems distant now?”)

It is important that aspirations are meaningful and motivating for the patient, not just “realistic” from the therapist’s point of view.

3. Making the adaptive mode a reality through positive action

The next step is to translate aspirations into concrete action. The therapist works with the patient to

• break down big goals into smaller, achievable steps (e.g., “Before I find a job, I can start by attending professional group meetings”),

• schedule regular activities related to aspirations (e.g., working on a resume every day, attending classes, meeting friends),

• find ways to realize values important to the patient in daily life (e.g., “How can you help others right now, even in small things?”),

• identify and overcome obstacles standing in the way of goals (e.g., symptoms, social anxiety, lack of money).

It is crucial that the patient experiences small successes that build confidence, motivation and a sense of competence.

4. Strengthening and building resilience

Throughout the process, the therapist helps the patient strengthen positive beliefs about themselves and build mental resilience. This is done through

• paying attention to the patient’s successes and progress (e.g., “I noticed that you managed to go to a meeting yesterday, even though it was difficult for you – what does that say about you?”),

• asking questions that encourage reflection on one’s own abilities (e.g., “How did you manage to do it?”, “What supported you then?”),

• helping to draw constructive conclusions from difficulties (e.g., “What did you learn from this situation?”, “What can you do differently next time?”),

• strengthening self-confidence and ability to cope with challenges.

The goal is to gradually develop a more adaptive way of thinking about oneself, others and the future.

Application of CT-R in various contexts

CT-R can be used in a variety of contexts, from individual therapy to hospital wards and family therapy

Individual therapy

In individual therapy, CT-R focuses on building a strong therapeutic relationship and exploring the patient’s individual interests and aspirations. It is crucial that each session begins by activating the adaptive mode, such as by talking about the patient’s favorite topics.

Typical CT-R session structure:

1. Accessing adaptive mode (e.g., talking about a favorite topic, listening to music together).

2. Connecting with the previous session and defining the purpose of the current one.

3. Developing aspirations and values.

4. Problem solving in the context of aspirations (e.g., “How do your symptoms affect your dream?”, “What can you do to get closer to it anyway?”).

5. Planning activities between sessions.

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Group therapy

CT-R can be used in group therapy, which provides additional opportunities for bonding and mutual support between participants. Phases of CT-R group therapy

1. Accessing and energizing the group’s adaptive mode (e.g., listening to music together, doing activities together).

2. Developing group members’ aspirations.

3. Planning and undertaking joint activities (e.g., joint projects, meetings).

4. Solving problems together.

5. Strengthening positive beliefs and resilience.

CT-R groups may focus on joint projects related to members’ aspirations (e.g., art group, sports group, professional group).

Hospital branches

CT-R can be implemented in psychiatric wards, creating a therapeutic environment focused on recovery. Key elements:

• creating opportunities for activity and social interaction,

• involving patients in planning ward activities,

• offering patients meaningful roles and responsibilities (e.g., helping to organize meetings, leading a group),

• linking activities on the ward to patients’ aspirations,

• reinforcing positive experiences and successes

CT-R helps transform wards from passive environments into dynamic communities that support recovery

Working with families

CT-R recognizes families as important partners in the recovery process. CT-R therapists work with families to

• understand the patient’s strengths and interests,

• support the patient’s aspirations and goals,

• create opportunities for positive family interactions,

• strengthen positive beliefs and resilience of the whole family.

The family can play a key role in energizing the patient’s adaptive mode and supporting his or her aspirations for the life he or she wants to lead

Effectiveness of CT-R – current state of research

Research confirms the effectiveness of CT-R in treating serious mental disorders. Key findings

• improvement in patients’ social and occupational functioning,

• decreased severity of negative symptoms (e.g., apathy, lack of motivation) and positive symptoms (e.g., delusions, hallucinations),

• increased motivation and commitment to treatment,

• improved quality of life and patient satisfaction

In a randomized controlled trial, CT-R improved community participation, motivation and positive symptoms to a greater extent than standard treatment, and the effects persisted 6 months after treatment. Importantly, benefits were seen regardless of disease duration, supporting the premise that “no one is too sick to not get better.“

CT-R is now recognized as evidence-based practice for people with serious mental disorders, including in forensic psychiatric and prison settings. In 2025, CT-R is being widely implemented in health care systems (including in the US), and its principles are being operationalized for interdisciplinary teams.

Challenges in applying CT-R recovery-oriented cognitive therapy

Although CT-R is a very promising approach, its application can come with some challenges

• it requires patience and creativity on the part of the therapist, especially in the beginning,

• patients may initially be distrustful or reluctant to engage,

• implementing CT-R in facilities may require a change in organizational culture (e.g., from “control” to “support”),

• therapists need to be flexible and adapt the approach to individual patient needs.

Summary

CT-R recovery-orientedcognitive-behavioral therapy offers an innovative and effective approach to treating serious mental disorders. By focusing on patients’ strengths, aspirations and mental resilience, CT-R helps them lead more fulfilling lives, regardless of their diagnosis.

Although the implementation of CT-R can involve organizational challenges and requires therapists to be patient, flexible and change their work paradigm, the benefits for patients, families and treatment teams are significant. CT-R represents a paradigm shift in the treatment of mental disorders – from focusing on symptoms to supporting each person’s full potential. It offers hope and practical tools for patients, families and mental health professionals.

Bibliography:

• Grant PM, Beck AT. (2009). Defeatist Beliefs as a Mediator of Cognitive Impairment, Negative Symptoms, and Functioning in Schizophrenia. Schizophrenia Bulletin, 35(4), 798-806.
• Grant PM, Beck AT. (2010). Asocial Beliefs as Predictors of Asocial Behavior in Schizophrenia. Psychiatry Research, 177, 65-70.
• Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients with Schizophrenia. Archives of General Psychiatry, 69(2), 121-127.
• Grant PM, Bredemeier K, and Beck AT. (2017). Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals with Schizophrenia. Psychiatric Services, 68(10), 997-1002.
• Grant PM, Beck AT, Inverso E, Brinen AP, Perivoliotis D. (2020). Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions. Guilford Press.
• https://beckinstitute.org/blog/what-is-recovery-oriented-cognitive-therapy-ct-r/