Use of Palm computer as an adjunct to cognitive-behavioural therapy with an ultra-high-risk patient: a case report.

The use of cognitive-behaviour therapy (CBT) to treat individuals with schizophrenia has expanded dramatically over the past two decades. Initial case reports of successful treatments led to numerous randomized clinical trials supporting the use of CBT in this population.1-3 Recent studies have also provided promising results of the use of CBT to treat individuals at ultra-high risk (UHR) for psychosis.4-7 Successful CBT treatment is founded on active patient participation including completion of homework assignments such as daily logs of mood, thoughts and behaviours. This view has been underscored by Rush,8 who stated that homework assignments are crucial to treatment success. They help the patient ‘(i) develop objectivity about situations that are otherwise stereotypically misconstrued; (ii) identifies underlying assumptions; and (iii) develops and tests alternative conceptualizations and guiding assumptions’ (p. 110). In addition, homework assignments extend patients' exposure time to therapeutic material beyond the time spent in the session and allows them to ‘practise’ what was learned in therapy.8 Empirical findings support this view: Burns and Spangler9 demonstrated that the Beck Depression Inventory (BDI) dropped on average 4.35 points for every unit of homework completion. Similar results have also been reported by a number of other authors.10,11 While the focus of CBT with individuals with schizophrenia has been primarily on targeting positive psychotic symptoms, recently, attempts have been made to apply CBT to improve negative symptoms.12 This new focus may be in part due to the growing recognition of the link between negative symptoms and poor functioning in schizophrenia.13 However, these very negative symptoms, the target of treatment, may themselves hinder the effectiveness of CBT. Among patients with schizophrenia, several barriers to CBT homework completion have been identified including avolition, ineffective decision-making, social withdrawal, distractibility and difficulties initiating activities.14-16 These barriers, along with difficulties in memory and executive functioning, represent some of the core features of schizophrenia. Thus, these negative symptoms and cognitive impairments, which are also commonly present in individuals at UHR for psychosis,17,18 present unique challenges for treatment success. The use of electronic devices such as Palm computers to administer homework assignments offers a number of advantages that may be particularly useful as part of CBT with individuals who display negative symptoms or cognitive difficulties: first, the use of palm computers as part of real-time, real-world (in vivo, in situ) daily functioning avoids the retrospective recall associated with standard, paper-based, daily homework logs – a feature that may be particularly important given the memory difficulties experienced by many individuals with schizophrenia and UHR status.19,20 Second, given the prevalence of avolition in these populations, the ability to preprogramme the Palm computers to sound alarms to prompt patients to complete homework assignments may be a useful feature. Delespaul21 described a number of case reports in which completion of (paper-based) daily logs was triggered using programmable wristwatches as part of a successful psychotherapy with individuals with schizophrenia-spectrum disorders. Third, in comparison with standard paper-and-pencil tasks, Palm computers can provide a direct time-stamp measure of homework compliance including precise homework completion times. This feature may increase therapists' confidence that the homework assignment was actually completed in a timely manner (rather than just prior to the session). Finally, Palm computers offer an easier method to customize questionnaires and incorporate branching – that is, presentation of different questions based on the subjects' responses to previous items. Currently, there are no published reports about the use of Palm computers as an adjunct to CBT with individuals with schizophrenia or who are at UHR for psychosis. We describe a case report of using a Palm computer as an adjunct to CBT with a UHR patient with high IQ and intact insight, whose negative symptoms, although predominant, have not yet coalesced. Our primary aims were to assess the feasibility of this methodology to augment homework completion and overcome the treatment barriers associated with negative symptoms and cognitive difficulties. In particular, we were interested in whether the use of a Palm computer would increase the completion rate of daily logs of mood, thoughts, symptoms and social contexts.