Learning and Consideration of Cognitive Behavioural Therapy Application - Essay Example

Cognitive Behavioral Therapy: Reflective Account of Learning and Consideration of CBT application to a Client with Mild Depression Problem within my own Practice Name Course Institution Date Table of Contents Table of Contents 2 1.0Introduction 3 1.1 Purpose 3 1.2 Review of Literature: 3 1.2.1 Background of CBT, and Relevance to Practice 3 1.2.2 Critical Analysis and Review of CBT: 5 1.3 Reflection Framework 6 2.0 Expected Learning Outcomes before CBT Intervention 7 3.0 Learning Reflection During and After CBT Intervention 7 3.1 Description of Clinical Case 7 3.1.1 Activities Undertaken: 8 3.1.2 Cognitive methods used: 8 3.1.3 Behavioral Methods Used: 9 3.2 Feelings 9 3.3 Evaluation of Experience 9 3.4 Analysis: Reflections and Learning Opportunities 10 3.5 Reflection on Role-Plays and Formative Assessment 11 3.6 Conclusion 12 Bibliography 12 1.0 Introduction 1.1 Purpose This paper explores the application of Cognitive Behavioral Therapy on a 30-year-old woman presenting with mild depression symptoms. For confidentiality and ethical purposes of this paper, I will call the client Mrs. Gill. Further, details of the clinical case including medical history are outlined in the Description section. In particular, this paper gives a reflective account of learning in relation to application of the principles of evidence-based CBT. To achieve this, the paper incorporates critical analysis of how various techniques are linked to evidence based CBT within my practice area, and a critical review of learning gained via role-plays and formative assessments carried out in class. 1.2 Review of Literature: 1.2.1 Background of CBT, and Relevance to Practice Caring for patients with mental and behavioral disorders requires integration of clinical skills, professional knowledge, interpersonal skills and experiences. The central activity in practice is therefore, that of using ‘self’ as the means of establishing and attaining effective nurse-client relationships. Consequently, Cognitive Behavioral Therapy (CBT) is one of the change interventions that rely on collaborative and therapeutic relationship and empowering with the treatment outcomes dependent on active participation of the client. The central idea in CBT is that all behavior (normal and abnormal) is attained and sustained ways that are identical (Whitfield, 2010). This is consistency with the principles of learning theory, which emphasizes on the role of operant and classical conditioning. The extensive evidence base of CBT is well documented and recommended as a treatment modality with clear guidelines for best practices (Whitfield, 2010). Although reflection plays a critical role in CBT, it has been conspicuously absent in CBT literature leading to misconceptions that CBT therapists don not reflect (Wright, 2006). With this background, this paper demonstrates that nurse students and CBT therapists use various methods such as self-reflection, self-supervision, and reflective journals as well as a variety of data from multiple sources such as CBT literature, client presentations and self-reflections to reflect on their learning and practice. According to the International Institute for Cognitive Therapy, CBT is a psychological approach that relies on scientific principles of which research has shown effectiveness towards diverse range of problems (International Institute for Cognitive Therapy, 2014). CBT intervention encompasses approaches such as cognitive therapy (CT), and rational emotive therapy (REBT). CBT therapists work with individual patients, families and other groups (IICT, 2014). Usually, therapists work with clients to identify problems and develop understanding of existing relationships between feelings, thoughts and behavior. The CBT approach relies on a shared view between the therapist and the client with regard to individual’s problem (IICT, 2014). Whether in conjunction with other interventions or medications, CBT approach can be applied to help individuals irrespective of their backgrounds or preferences. This is especially important if such an approach is patient-centered. Further, the practice of CBT involves different levels that vary with regard to therapist’s skill levels (IICT, 2014). For instance, formulation-driven CBT are used for clients who having sought help and require professional intervention, are unable to help themselves. There are also Specific CBT interventions designed for specific areas and Computerized CBT and self-help resources (IICT, 2014). The changing health care environment requires that CBT therapists seek and analyze intervention approaches that entail partnership and alliance. Research shows an important trend towards making personal therapy a mandatory requirement in training CBT therapists. First, there is merging trend towards incorporating reflection in CBT training in relation to self-reflection and self-practice on the part of the therapist. Self-reflection and self-practice forms critical training tools that give CBT therapists personal-based experiences through practicing CBT techniques (Bennet-Levy et al., n.d). CBT therapists use two approaches to deliver CBT: via co-therapists or on a format that uses individual’s manual workbook (Bennet-Levy et al., n.d). 1.2.2 Critical Analysis and Review of CBT: A critical review of existing literature shows extensive research on CBT and its effectiveness as an intervention. In particular, there are many questions over the differential effectiveness of CBT for various depression-related disorders. Research shows that anti-depressants are not effective to many people (Kennard et al., 2008). Thus, medication is now seen as an option given the potential effectiveness of CBT. The predominant assumption in existing literature is that the combination of anti-depressants and cognitive therapy achieves better outcomes (Rohde, et al., 2008). According to Butler et al. (2006), there are important questions about the long-term efficacy of CBT. A critical search of literature shows sufficient evidence cognitive therapy reduces potential relapses in patients initially presenting with depression. Overall, available research on CBT documents the following benefits of CBT: Relatively shorter time for completion of treatment Skills learnt during CBT sessions are practical and helpful for everyday coping Its structure nature provides flexibility for introducing new ideas and new solutions Demonstrated efficacy in treating many forms of depression Potential drawbacks of CBT: Existing literature shows a number of potential drawbacks and limitations of CBT approach. Requires commitment from both the client and the therapist Unsuitable for clients with complex manifestations of mental difficulties, which could be associated with its highly structured nature Emphasizes on the capacity of an individual client to change their behaviors, thoughts and feelings and does not address broader systemic issues such as issues affecting entire families 1.3 Reflection Framework The overall approach envisaged in this paper is to use the 6-stage reflective model described by Gibbs (Jasper, 2003). This model emphasizes on description of what happened, discussion of individual experiences, feelings and thoughts, evaluation of these experiences, analysis of the situation, conclusion, and an action plan for dealing with issues if they arise again. Source: Melanie, Jasper, Beginning Reflective Practice. Nelson Thorns, 2003 2.0 Expected Learning Outcomes before CBT Intervention I expected to achieve the following outcomes after the CBT case: Grasp of key principles and concepts of CBT to work with young people Describe evidence base supporting CBT Formulate CBT intervention plan Apply CBT theoretical principles to the case Application of research based knowledge Reflect on practice Although computer-based CBT has been shown to treat depression, I did not use this approach because I did not have access to the relevant multi-media software for exposure therapy. Research shows that computer-based CBT can help decrease the time taken by a clinician to offer standard treatment and provide effective psycho-educational experiences (Bennet-Levy et al., n.d). 3.0 Learning Reflection During and After CBT Intervention 3.1 Description of Clinical Case In this essay, I explore the application of CBT on a 30-year-old patient whom I will call Mrs. Gill. Mrs. Gill exhibited signs and symptoms of depression with persistent low mood and sadness, palpitations and headaches as well as hallucinations. Mrs. Gill had family support from Mr. Gill and her two children. The family visited the patient on a regular basis. I was attached to the community-based nurse who attended to Mrs. Gill’s case. I visited Mrs. Gill regularly over a period of 3 months when a family friend confided that she would not continue with the treatment because she has not seen any improvements. While this paper describes the application of the various tools and concepts, I will share personal thoughts and ideas about the experience with CBT application. Mrs. Gill evoked memories of other patients presenting with similar or related conditions and requiring similar intervention as well as what I would do to help patients in the future. Together with the community nurse, we drew up a plan outlining the various procedures for CBT delivery. We conducted an initial assessment session and discussed the available methods of self-help with Mrs. Gill. The client was informed the role of the community nurse. 3.1.1 Activities Undertaken: . Problem definition and goal setting: We asked the client to explain her problem We asked client what she would like to achieve via the therapy In the beginning of the sessions, Mrs. Gill updated us how she was feeling and what she would like to achieve. She explained that she felt isolated and wanted to feel better and ‘rediscover’ herself. Existing literature shows that the key behavioral concepts for modern CBT methods include modification of depressive behaviors using behavioral techniques, using exposure therapy to address behavioral and psychological responses and using interventions that are suitable for helping patients to cope as well as problem-solving skills (Wright, 2006). Examination of thoughts and identification of signs and symptoms: We analyzed client’s thoughts and behaviors as she described the problem and her situation During this step, we informed client about Ellis ABC theory and asked her to conceptualize her situation and problem. Eradicating identified behaviors and other cognitive techniques: Various techniques can help individuals deal with irrationality. These include cognitive, emotive and behavioral techniques (Guterman and Rudes, 2005). Some of the techniques I used in this case include teaching client on how to identify self-defeating feelings, thoughts and behaviors as well as various strategies for challenging irrational disputes such as reframing situations, problem-solving situations, and to manage stressful people. I also employed role playing, modeling and bibliotherapy techniques. Problem and goal reevaluation and homework assignments 3.1.2 Cognitive methods used: I employed the following cognitive methods: Guided discovery Though change records Role play Evidence examination Socratic questioning 3.1.3 Behavioral Methods Used: Activity scheduling Relaxation and breathing training Copying techniques Response and exposure prevention 3.2 Feelings I remember having mixed feelings during the course of the intervention. Mrs. Gill had surprised me confiding in her friend but concealing treatment matters from her family and even the therapists. While we as nurses worked hard to support Mrs. Gill, she appeared to have prepared for this and decided quietly to make the matter personal. My initial reaction was feeling betrayed even as the nurse officer talked with Gill on this matter. I found it difficult to focus on key issues. I remember Gill confronting the nurse as I sat quietly on the opposite chair. I also remember making supportive gestures while the attending nurse made expressions that I leave the matter to her. Perhaps there were issues that I had not gained enough experience to deal with. Despite the mentoring process and clinical placements, I understood my feelings to be due to my lack of sufficient clinical experience. Generally, clinical experience plays an important role in developing nursing students learning (Ali and Panther, 2008). 3.3 Evaluation of Experience After the experience with CBT and its application, it raised important practical aspects of caring for clients with mental and behavioral disorders on me as a therapist. Besides the morals of learning clinical practice, the case in point prompted questions associated with my understanding of CBT. The various sessions increased my understanding about the various techniques used in CBT and the experiences of patients with these techniques. Overall, the experience convinced me that CBT is an effective therapy because I could associate with the client’s feelings throughout the sessions and not just the outcome of treatment. It is clear that therapists can offer CBT as a management approach or bio-psychological assessment (Ali and Panther, 2008). In particular, CBT is indicated under various circumstances including when the specific patient prefers psychosocial treatments, when the target problems exist and when medication has led to minimal or no patient improvements (Ali and Panther, 2008). This is different from my thoughts before the practical sessions. Now I have a better idea on why CBT is effective. First, with the various therapies suggested in the course of the study, I developed curiosity on what really makes the difference. I was wondering if differences were due to the principles or the techniques applied for each therapy. At this point, I have a clear understanding of the role of therapeutic relationship. 3.4 Analysis: Reflections and Learning Opportunities The experience with the client gave me uncomfortable feelings perhaps because it marked an important departure from theoretical approach to CBT intervention. Before this CBT experience, I used science to make vital decisions on what should be done as regards application of CBT and assumed that clients would naturally achieve benefits as described in common textbooks. Nothing is far from the truth, at least based on the experience I acquired with the CBT case. The CBT experience was not simply a logical application of the intervention: for me, it was about making choices, analyzing patient backgrounds, applying theoretical concepts and understanding why patients make certain decisions. More importantly, I learnt that CBT for depression and other uncomplicated disorders could be completed in shorter sessions. For instance, literature shows that 5-20 CBT sessions can help address anxiety disorders (Wright, 2006). Furthermore, it became apparent that the CBT sessions enhanced the patient’s ability to combat perceived problems through psycho-education. The importance of psycho-education has been emphasized in CBT (Wright, 2006). Earlier in this paper, we stated that reflection is an important strategy in learning and a vital element of effective supervision. In my experience, it appears that psychotherapy without the ability to make reflections results in unresolved professional and interpersonal relationships. More importantly, my experience with CBT emphasized the importance of professional supervision. Research shows that CBT demonstrated efficacy has led to increased dissemination of routine clinical practice settings (Rakovshik et al., 2010). According to Rakovshik et al. (2010), one of the most important strategies in CBT training is to increase dissemination of information and enhanced supervision of therapists through supervision and practice reflection (Rakovshik et al., 2010). I learnt a lot from the interaction with the clients and their families as well as mentorship from the professional therapist. For instance, working with the community professional therapist in the CBT application provided opportunities for developing knowledge and skills, and supporting learning transfer into practice. Research shows that mentorship provides students with opportunities to practice the theory they have learnt and thus the importance of providing students with appropriate supervision and support (Ali and Panther, 2008). 3.5 Reflection on Role-Plays and Formative Assessment From the formative face-to-face role-plays and interactions with the client and the supervisor helped in exploring the personality and character articulated within this clinical environment. First, it enabled assessment of new knowledge gained through this activity as well as my individual contribution given the design of the task. In reflection, keeping mental focus on the situation of the client depends on both careful listening of client’s narrative as well as letting him or her appreciate that you are also listening. Getting feedbacks on my performance helped develop insights about best practices regarding the application of evidence-based practice in CBT. 3.6 Conclusion The reflection above about the application of CBT principles and concepts has led to three broad conclusions. First, that CBT is entirely an action-directed and a solution-based approach to therapy indicates the importance of a therapist being client-centered. My initial experience with client in this case emphasized on theoretical understanding of CBT principles and concepts. During the process, I learnt that CBT intervention requires much more than that. CBT therapists confront client and work situations that they are not prepared for. This calls for effective listening and interpretation skills and ability to make important decisions based on evidence, rather than theoretical assumptions. Secondly, I conclude that experience is particularly important in the CBT administration. CBT therapists have to recognize that they can learn from patient situations, the ultimate goal of helping patients make ‘own’ decisions. The third conclusion from this reflection is that to understand client perspectives on their psychological or behavioral problem, one must listen and interpret accurately patient’s thoughts, feelings, attitudes and behaviors. How does the client describe her feelings, how does she refer to what she did, and what body language does she express? The way the client shares the story and how the entire process made us (therapists and client) feel is pertinent to the success of CBT intervention. Bibliography Ali, A. & Panther, W. (2008). Professional development and the role of mentorship. Nursing Standard, 22, 42, pp. 35-39. Bennet-Levy, J. Thwaites, R. Chaddock, A., & Davis, M. (n.d). Reflective practice in cognitive behavioral therapy: the engine of lifelong learning, n.d. Accessed April 14, 2014 from http://www.cbttraining.com.au/uploads/images/documents/Reflection_chapter_6.pdf Guterman, J., & Rudes, J. (2005). A solution-focused approach to rational-emotive behavior therapy: Toward a theoretical integration. Journal of Rational &Cognitive-Behavioral Therapy, 233, 223-244. International Institute for Cognitive Therapy (2014). What are cognitive and/or behavioral psychotherapies? Accessed April 14, 2014 from http://www.learncognitivetherapy.com/cognitive_therapy.htm Jasper, M. (2003). Beginning Reflective Practice. Nelson Thorns. Malikiosi-Loizos, M. Personal therapy for future therapists: reflections on a still debated issue. The European Journal of Counseling Psychology, 2, 1(2013). Rakovshik, S. and McMnus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: a review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30, pp. 496-516 Russell, M. Saint, L. M. et al. (2013). Assessing suitability for short-term cognitive-behavioral therapy in psychiatric outpatients with psychosis: a comparison with depressed and anxious outpatients. Journal of Psychiatric Practice, 19(1), pp. 29-41 Whitfield, G. (2010). Group cognitive-behavioral therapy for anxiety and depression. Advances in Psychiatric Treatment, 16, pp. 219-227. Williams, C. & Garland, A. (2002). A cognitive-behavioral therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 8, pp. 172-179 Wright, J. (2006). Cognitive behavior therapy: basic principles and recent advances. Focus, 4, pp. 173-178. Butler, A. Chapman, J. Forman, E. & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review,26, pp. 17-31 Kennard, D. Emslie, J. Mayes, L. et al. (2008). Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. Journal of American Academy for Child and Adolescence Psychiatry, 47, pp. 1395-1404. Rohde .P. Silva, G. Tonev, T., et al. (2008). Achievement and maintenance of sustained response during the Treatment for Adolescents With Depression Study continuation and maintenance therapy. Arch Gen Psychiatry, 65, pp. 447-455. Read More