Cognitive Behavioural Therapy - Essay Example

NURSING Cognitive behavioral therapy used in the management of schizophrenia is one of the many interventions that can be used in patients suffering from schizophrenia. Schizophrenia on the other hand refers to any of the several psychotic disorders that are characterized by disturbances of thoughts and language, distortions of reality and withdrawal from social contact. Therefore, with this brief background information this paper will seek to critically explore and examine the topic; cognitive behavioral therapy used with schizophrenia patients. In its quest to achieve this goal the paper will review the existing literature on this type of intervention. This will focus on the available studies and systemic reviews existing on this type of intervention. Types and focus of studies undertaken, methods adopted, findings, strengths, and limitations of the evidence will be the main subject to be considered in the literature review. The paper will then explore the intervention in details. This will involve definition of the intervention, principles, and components of the intervention undertaken with the client groups. Ways of implementation and evaluation of the intervention will also be explored coupled with short practice examples to illustrate knowledge of the implementation procedure. An explanation of how the intervention links with contemporary mental health policy guidelines and the challenges involved in working in accordance to the guidelines will also be explored. In the conclusion, the paper will examine the implications the intervention has for the mental health nursing practice and its impact on my nursing practice. Key words; CBT- Cognitive behavioral therapy, schizophrenia. Literature review Cognitive behavior therapy initially used in the treatment of individuals with mood and anxiety disorders has been introduced in the recent years to help with the treatment of schizophrenia patients. CBT has been gradually endorsed to target one of the core symptoms of schizophrenia which has been resistant to treatment with medication alone. This intervention has also been employed to address other symptoms of schizophrenia like comorbid mood and anxiety disorders. Treating schizophrenia with CBT is not a new approach as Beck had successfully described its use in the treatment of those patients with acute symptoms back in 1952 (Amir & Taylor, 2012). Studies have revealed that cognitive therapy was effective and reduced positive symptoms at a higher rate during a 12 week period that followed hospital admission compared to patients who received equal amount of support and activity therapy. When a follow up was done after nine months the group that received cognitive therapy showed a significant fewer positive symptoms than the control group (Sheldon, 2011). Another study which aimed at treating persistent and chronic symptoms of schizophrenia found that half of the people with schizophrenia demonstrated psychotic features while 20% exhibit weak or sporadic features (Malik, Kingdon, Pelton, Mehta & Turkington, 2009). These studies which have mainly been done in the united kingdom, where the approach is broadly disseminated have summarized the results of these studies and reviews as follows; Randomized Controlled Trials (RCTs) have demonstrated moderate effect sizes for positive and negative symptoms at the end of therapy and having sustained effects. The intervention has also been effective in both research as well as clinical setting. Delusions and hallucinations have also been shown to respond well to CBT. Studies are also revealing that CBT is not effective when individuals or patients do not view themselves as having a mental health problem, have extreme negative systems or poses delusional systems (Rathod, Phiri & Kingdon, 2010). Individuals experiencing comorbid disorders such as substance misuse also do not find the intervention to be effective because it is very difficult to engage and treat them. Factors such as shorter duration of untreated illness, shorter duration of illness, early work with acutely psychotic inpatients and the female gender has been shown to predict or give better outcomes with CBT for patients with schizophrenia. Similarly, outpatient individuals also demonstrated a positive response to CBT in shorter durations of illnesses and when symptoms were less severe (Thomas, Hayward, Peters, Gaag, Bentall, Jenner & McCarthy, 2014). Techniques and interventions under cognitive therapy include the following; attention narrowing, attention switching, increased activity level, internal dialogue, modification of self-statement, social disengagement, and engagement. Other techniques include; de arousing techniques, increasing reality or source monitoring and peripheral questioning. Therefore, the techniques to help manage schizophrenic patients have been summarized as follows; the first step involves developing a therapeutic alliance based on the patient’s perspectives. Another technique will involve developing alternative explanations of the symptoms of schizophrenia. A reduction of the impacts of positive and negative symptoms will also be considered (Rakovshik, & McManus, 2010). Finally, alternatives to the medical model to address medication adherence are offered. A theoretical support for the use of CBT for schizophrenia demonstrate how neurocognitive impairment in the premorbid state makes individuals to become vulnerable to aversive experiences like failing in school work or not performing at the workplace. This further causes the individual to experience dysfunctional beliefs like believing they are inferior and thus further leading to dysfunctional cognitive appraisals and maladaptive behaviors such as social withdrawal (Hall & Tarrier, 2013). Consequently, this conditions increase psychophysiological stress. In treating schizophrenia typical CBT techniques that can be employed include; building trust and engagement between the patient and the therapist, working in collaboration with the patient in order to understand the meaning of the symptoms, trying to understand how the patient interprets his past and present events focusing mostly on those the patient feels are the cause of his current state, normalizing the experiences then educate the patient about the stress vulnerability model, and finally socializing the patient to the cognitive model by focusing on the thoughts, feelings and behaviors of the patient . Negative symptoms of schizophrenia such as social withdrawal, anhedonia, amotivation, and anergia can be addressed with activity scheduling, graded task assignments, assertiveness training, pleasure ratings, and behavioral self-monitoring (Bradley, Greene, Russ, Dutra & Westen, 2014). It has also been discovered that people who suffer from schizophrenia tend to have comorbid disorders such as depression, anxiety, and substance use. CBT has proved effective in the management of these problems and even to those that result from posttraumatic stress disorder and some phobias. Individuals suffering from schizophrenia sometimes tend to suffer from phobias which can only be managed by getting support from the community and implementing behavioral plan (Turkington, Kingdon & Weiden, 2014). Symptoms of anxiety have also been found to have adverse effects on the lifestyle of patient with schizophrenia. When it comes to substance abuse it has also been found that patients with schizophrenia tend to find themselves struggling with substance use disorders displaying a higher comorbidity rate of 47%, the highest than any other mental disorder (Kowalik, Welle, Venter & Drachman, 2011). CBT has also been used to target individuals who are suffering from disabilities that arise from experiences of failure and demoralization and especially those who are tasked with major role functions. CBT proved beneficial in addressing such problems by a study which was done in India. The study revealed that CBT was beneficial and those patients who were enrolled in it worked longer hours and performed better compared to their counterparts who received standard vocational support (Turkington, Dudley, Warman & Beck, 2014). Suicide has also remained to be another challenge for patients with schizophrenia. Application of CBT has also shown some promising outcome in reducing suicidal ideas in these patients. In one study 90 patients were randomized to either befriending groups or CBT, which happen to receive 19 individual treatment sessions over a period of nine months. The two groups experienced a reduction in both positive and negative symptoms of depression and schizophrenia with the group with the CBT showing improvements at follow up. From this experiment individuals that were enrolled for the CBT displayed a reduction in ideas of committing suicide (Malik, Kingdon, Pelton, Mehta & Turkington, 2009). From the above literature review it is evident that CBT significantly improves both the negative and positive symptoms in the different subgroups of individuals or patients suffering from schizophrenia. The idea of committing suicide or suicidality by patients with schizophrenia was limited or lacked evidence when CBT was used as an intervention in managing the disorder. This indicated an improvement or decrease of suicidality when used on patients with schizophrenia. In the randomized controlled trials conducted, the dropout rates of CBT were significantly low compared to other interventions like pharmacological therapy. The 12% drop out rate is a reflection of the preferences of the service users and this should send some message to healthcare providers on ways to improve their service delivery (Lynch, Laws & McKenna, 2010). Another merit of this intervention is that it is cost effective. When compared to other treatments or interventions like befriending and supportive counseling, CBT demonstrated superiority in durability over all the other interventions (Rakovshik & McManus, 2010). CBT has also been shown to equip schizophrenic patients or those with other mental illness with skills that they can use to counter the symptoms of schizophrenia long after the termination of the intervention. Methodological limitations of this type of intervention were found to be similar to those of other research into psychotherapy. Some of the limitations relating to the methodologies researching into this intervention include blinding, comparison groups, and inclusion and exclusion criteria. Cognitive behavioral therapy as an intervention for patients with schizophrenia. Cognitive behavior therapy is a type of mental health counseling that involves talking about how one thinks about themselves, the world, and other people. It also involves talking about how one’s feelings and thoughts affect their action. This type of talking treatment tend to focus on the present, that is “here and now” difficulties and problems. It normally aims to improve the state of the patient‘s mind at the present. This type of therapy has mostly been applied in the management of schizophrenia (Penn, Waldheter, Perkins, Mueser & Lieberman, 2014). Schizophrenia which refers to the several psychotic disorders that are characterized by distortions of reality normally involve having difficulty with thinking, activities of daily living, communication, relationships and motivation. Individuals suffering from this disorder normally lack social and working skills coupled with inexperience. Other than cognitive behavior therapy, other therapies have been developed to manage schizophrenic patients and they include. Individual psychotherapy; this involves patients having regular sessions with a therapist and focus is put on past or current problems, feelings, relationships, and thoughts (Mohr, Burns, Schueller, Clarke & Klinkman, 2013). Coming into contact with professionals, these individuals tend to show improvements by being able to differentiate between what is real and what is not thereby acquiring skills that can help them solve problems in the future. Another therapy is rehabilitation which involves vocational and job counseling, social skills training, education in managing money and social skills training. Family education is also another therapy used in managing schizophrenia. This therapy entails involving the family members in the management and care of schizophrenic patients (Shonin, Van Gordon & Griffiths, 2014). Studies have shown improvements in the conditions of those who involve their families in their management than those who battle the symptoms alone. Another effective therapy is self-help groups. This involves outreach programs and community care which help in preventing noncompliance, relapse, repeat hospitalizations, and legal problems. One such organization is the National Alliance on Mental Illness (NAMI) which provides information on the type of treatment and support for patients with schizophrenia together with their families (Gabbard, 2014). There are various methods of accessing CBT. These include the therapist, computerized or internet delivered type of CBT, reading self-help materials, and group educational courses. The therapist method of accessing CBT involves face to face sessions between the patient and the therapist which consist of 6-18 sessions each lasting about an hour with a gap of 1-3 weeks between the sessions (Dixon, Dickerson, Bellack, Bennett, Dickinson, Goldberg & Kreyenbuhl, 2010). CBT closely rely on the scientist-practitioner model whereby research and clinical practice is informed by a scientific perspective, an operationalization of the problem, measurement of the changes and attainment of goals. These are normally achieved through homework assignments in which the patient and the therapist work together to complete before the next session. This type of therapy normally involves the patient fully, and this has been demonstrated in the type of assignments given like talking to strangers especially patients suffering from anxiety. Internet delivered or computerized CBT is a form of therapy where CBT is delivered by an interactive computer interface via a personal computer, interactive voice response system and the internet instead of a human therapist. This form of therapy has been found to be cost effective, and also effective in patients who fear face to face therapy from fear of stigma. Reading self-help materials is also another method used to deliver CBT (Bracken, Thomas, Timimi, Asen, Behr, Beuster & Yeomans, 2012). This method is only effective when it is guided by a medical professional. It can also be delivered in group educational course where patient participation in such groups has been found to be effective. There are various types of CBT applied in various situations. This includes brief CBT, cognitive emotional behavioral therapy, structured cognitive behavioral therapy, moral reconation therapy, and finally stresses inoculation training. The brief CBT is normally applied in situations where there are constraints in administering the therapy sessions. It was initially developed for soldiers who were on duty oversee to help prevent suicide. The sessions can last up to 12 accumulated hours (Rathod, Phiri & Kingdon, 2010). The treatment is broken down into various categories that include orientation, skill focus, and prevention of relapse. Another type is cognitive emotional behavioral therapy which was initially meant for individuals suffering from eating disorders. It has since been applied in the management of problems such as obsessive compulsive disorder, post-traumatic stress disorder, anger problems, anxiety, and depression. This type of CBT normally combines aspects of CBT and dialectical behavioral therapy in order to improve the tolerance and understanding of individual emotions to prepare them for a long term therapy (Gunter & Whittal, 2010). It often used as a pretreatment therapy. Structured CBT affirms that behavior is inextricably related to emotions, thoughts, and beliefs. Structured CBT differs from CBT in that it is delivered in a highly regimented format and again it is a finite and predetermined process that is influenced by the participation of the individual to become personalized. It aims at achieving a specific result at a specific period of time. It has mostly been applied in the field of criminal psychology to reduce recidivism and also to counter addictive behavior like substance misuse in schizophrenic patients. Moral reconation therapy is a type of CBT that has been largely applied in criminals to reduce the risk of further engagement into crime. In this method groups meet frequently like weekly for duration of 3-6 months. It has been largely put to use in outpatient settings and correctional units with an aim to reduce costs (Jones, Hacker,Cormac, Meaden & Irving, 2014). Stress inoculation therapy training involves helping patients cope with anxiety or stress after stressful events. The method utilizes three phase approach to address the patient’s needs. The first, phase involves conducting interviews that include psychological testing and patient self-monitoring (Safren, Sprich, Mimiaga, Surman, Knouse, Groves & Otto, 2010). The second phase focuses on the acquisition of skills and rehearsals from the earlier phase. The third phase involves application of skills learnt and follows up. A practical implementation and evaluation of the intervention will be discussed in the subsequent paragraphs. CBT works by breaking down overwhelming problems into manageable smaller parts. This enables the individual to see how the problems are connected and how they affect them (Gooding & Tarrier, 2009). These small parts are; the situation which refer to a problem, an event or even a difficult situation. This is then followed by thoughts, emotions, physical feelings, and finally actions. Therefore, CBT aim to help individuals react positively to most unpleasant situations by transforming their way of thinking. The example in the table below will demonstrate helpful and unhelpful ways to reacting to a situation. The situation in this case may refer to a case where you have had really a stressing day, and then as you take walk around town you come across a workmate who may accidentally ignore you. This event can be detrimental or helpful depending on how you treat it. The table below describes both scenarios; Unhelpful Helpful Thoughts Why has he ignored me- it seems he does not like me. Why is he keeping to himself so much- it seems he has a problem. Emotions Sad, low and rejected. Feel positive and concerned for the other person. Actions Resorts not to talk to him again because he has ignored me. Or even avoid social contact. Should check on them and find out if they are doing well. From the table it is evident that the different thoughts of the individual have led to him feeling and acting different. One is positive and the other is negative (Dunn, Morrison & Bentall, 2002). If not checked this vicious cycle of thoughts, emotions and actions can lead to an individual believing in unrealistic and unpleasant things about themselves thus worsening their conditions and especially if they are schizophrenic. When stressed people tend to jump to conclusions that are extreme and not helpful, therefore CBT is normally employed to help break this vicious circle of altered thinking, feelings, and behavior. CBT also aim to get the individual to a point where they can work to change these negative thoughts at the individual level (Jauhar, McKenna, Radua, Fung, Salvador & Laws, 2014). The work generally involves establishing a link between the thoughts, feelings, and actions in a collaborative and accepting manner between the therapist and the patient or client. The duration normally consists of 12-20 sessions. The phases of this therapy proceeds as follows; the assessment phase, it involves the therapist allowing the client to express their thoughts about their experiences (Wykes, Huddy, Cellard, McGurk & Czobor, 2014). Progress is then monitored by the use of rating scales and the results shared with the patient. To patients with chaotic lifestyle, the use of diagrams and written materials can prove to be useful (Hogarty, Greenwald, DiBarry, Cooley, Ulrich & Flesher, 2014). The formulated symptom causation and maintenance model is also shared to the client. The engagement stage involves questioning the client by employing techniques like the Socratic questioning which involves drawing out the clients own understanding of the situation and ways of coping in a process of guided discovery (Clark & Beck, 2010). Empathy and flexibility is demonstrated when dealing with the clients feelings. It is also important to demonstrate to the patient that the therapist does not harbor all the answers and the solution will only come through cooperation by the two. The client is then helped to organize his confusing experiences using various models like the ABC model. This model focusses on explaining the event, beliefs and consequences of the actions of these individuals (Brabban,Tai & Turkington, 2009). Goals that are measurable, realistic, and achievable are then set. Another phase is the normalization. This help in normalizing the psychotic problems by helping the patient feel less alienated and stigmatized. The therapist then conducts a critical collaborative analysis to help the patient appreciate the illogical deductions and conclusions. Then finally is the phase of developing alternative explanations to the experiences of the client (Rakovshik & McManus, 2010). It is important to let the patient develop their own alternatives to previous maladaptive assumptions. The strength of CBT is that the patient can continue to practice and develop skills even after the sessions are over. From the paper it is evident that treating schizophrenia with CBT also faces certain challenges. One of the major challenges has been dissemination and implementation of this intervention into a system that has mainly focused on pharmacological treatments and community support services. Among the sub groups of patients, CBT has experienced some challenges when dealing with the aging and elderly populations (Sheldon, 2011). Some of the challenges faced here include the cohort effect, established role, and processing speed decisions which frustrate the benefits of this intervention in the elderly populations. Conclusions In conclusion it is evident that CBT in schizophrenic patients has been so effective in the management of the several psychotic disorders. It has proved to be effective in the several studies conducted with only a few challenges which can be improved with further research in the future. Another challenge that is facing application of this intervention is the limited access and its use in the field of mental health (Brabban, Tai & Turkington, 2009). Therefore, it would be beneficial if all the psychiatrists endeavored to acquaint themselves with basic principles of CBT in managing schizophrenia and other psychotic disorders in order to incorporate that knowledge in mental health service delivery. With this knowledge the impact of this study on my nursing practice is that it acquaints me with adequate skills of CBT in managing psychotic disorders and also to help advocate for it use to increase its popularity. References Amir, N., & Taylor, C. T. (2012). Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy. 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