Professor and Vice Chair Department of Psychiatry and Psychiatrist-in-Chief Keck Medical Center University of Southern California and Assistant Dean International Relations Keck School of Medicine University of Southern California Los Angeles, CA
When asked to review Back to Life, Back to Normality, I enthusiastically accepted. For years, I had heard Dr. A.T. Beck praise the work Drs. Turkington and Kingdon and colleagues had done in using cognitive therapy (CT) to successfully treat patients with chronic psychosis in the United Kingdom. What an excellent opportunity to learn more of their work and application of CT techniques in this challenging patient population. After reading the book, I was a bit disappointed and had a few serious concerns over statements made to patients, which I will discuss. In essence, this is a CT user guide for psychotic patients and their families. The book is 178 pages divided into nine chapters. The foreword was written by Dr. A.T. Beck and nicely highlights the strengths of the book. I am less confident than Dr. Beck that it “provides an excellent resource for mental health professionals working with patients with schizophrenia” (p. vii). The nine chapters include Where Do I Begin?, What is Normal?, Understanding Paranoia and Unusual Beliefs, Voices, Overcoming Negative Symptoms, Tablets and Injections, Why Me? Why Now? Understanding Vulnerability From a Cognitive Perspective, Helping Carers Help Themselves Using a Cognitive Approach, and Staying Well and Managing Setbacks.
Consistent with the CT approach to therapy, this book is focused, highly structured, easy to read, and easy to understand. Its liberal use of bolded-type very short paragraphs and boxed/bulleted content lists add to its readability. Each chapter begins with a concise overview, and many chapters offer classic CT homework exercises for the patient (which could be filled out in the book). Cartoons are also used to demonstrate key points, such as automatic thoughts (pp. 25–26) and stress (p. 151). I applaud the extensive use of graphs, tables, and clinical vignettes used in every chapter. These effectively reinforce the information being presented. In sum, the text offers a user-friendly, clinically applicable, concise overview of CT techniques. I agree with Dr. Beck’s introduction that this goal was achieved. However, despite its many strengths, including easy-to-understand explanations of key concepts, beautifully organized content, and many clinically useful patient activities, I am very concerned over the potential perception by patients and their families (and less-experienced mental health providers) that psychosis is normal. Schizophrenia is neither normal nor a variation of normality. It is a chronic disease.
A person eating a candy bar will experience a temporary spike in blood glucose, as will blood pressure readings elevate after running up the stairs. These normal physiological responses do not “normalize” the chronic conditions of diabetes and hypertension. I am sure the authors’ intent was to destigmatize mental illness, in general, and schizophrenia, in particular. In my opinion, this approach achieves the exact opposite. No other medical specialty attempts to normalize disease. If psychosis is normal, why seek treatment at all? Why should the government or insurance companies cover the cost to treat a normal condition? This logic has been used to justify limited funding to treat psychopathology worldwide and, in some cases, to question whether psychiatric disease even exists. Despite significant advances in clinical neuroscience made over the past 40 years, our field continues to be challenged by very limited public mental health literacy, resulting in ongoing stigma. I fully support every effort to destigmatize mental illness. Attempting to normalize it does not achieve this goal. Encouraging patients and their caregivers to strive to achieve the highest level of functioning possible is a laudable goal and one that is expressed in the book. It would benefit from an approach consistent with the medical model for chronic disease.
I recommend this book to experienced mental health providers wanting to learn more about CT in treating psychotic disease. It could be very useful for patients and caregivers after clarifying that the goal is not to normalize their illness but, rather, to help them achieve their highest level of functioning (a similar approach could be used for students). The book mentions treatment strategies, such as the use of outpatient mental health nurses, that only exist in the United Kingdom. Patients, caregivers, and providers need to be made aware of existing support resources available in the United States.
Finally, it is obvious when reading the book that the authors are CT experts with extensive clinical experience, which they skillfully share with the reader. Their approach is largely nonmedical, which is understandable because they are all PhD clinicians/researchers/educators. Hopefully, the stigma related to psychopathology will eventually cease to exist. Until it does, all mental health providers, educators, and researchers need to be sensitive to the impact of their well-intentioned efforts on those uneducated about mental illness.
Cognitive therapy is a valuable, underused treatment tool for psychotic patients. The authors should be congratulated for their work in advancing this approach to patient care but might consider a greater emphasis on a disease model when treating schizophrenia, a chronic disease.
David Baron, MSEd, DO, FACN
Professor and Vice Chair
Department of Psychiatry and Psychiatrist-in-Chief
Keck Medical Center
University of Southern California and Assistant Dean International Relations
Keck School of Medicine University of Southern California
Los Angeles, CA
The author declares no conflict of interest.