Cognitive Behaviour Therapy in Nursing Practice - Term Paper Example

CBT in nursing practice Nursing – An introduction The nursing profession is a science and an art, in which the primary aim is to promote quality of life (DR SL Van Sell, 2002). It includes a comprehensive set of activities and duties by which individuals and families are assisted in a range of human life experiences ranging from birth, sickness and end of life (American Nursing Association).In the course of providing treatment a nurse become a patient’s guide as they use their knowledge to help the patient cope with their illness. Thus nursing is a profession concerned with the total health care of the individual and their family. Such total health care constitutes the physical, psychological, sociocultural and environmental problems as related to daily life. ( SDSU). they relate to daily Florence Nightingale is the first person to start modern nursing practices and New Zealand was the first country to regulate nurses nationally ( Jone John Lewis). Nursing practise can be defined as the practice which involves the use of clinical judgment in providing help to patients so they can improve, maintain, recover health, and to cope with health problems and achieve the best possible quality of life no matter what their disease or disability is, until the point of death. (American Nursing Association, 2004). Thus nursing is "the protection, promotion, and optimisation of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations”. (American Nursing Association, 2004) Characteristics of nursing practice Nursing diagnosis is a statement of a patient problem, which has arisen out of unmet needs, whether these are physical, psychological, social (bio-psychosocial problems), economic and spiritual (Hunt & Maran 1986 p42). Nursing practice is based on a set of characteristics which defined the practice. Following is a list of nursing practice characteristics: Nursing serves a particular purpose - Nursing is performed with the goal of improving a patient’s health, healing, growth and development. It includes all steps required prevent disease, illness, injury, and disability.. Nursing involves educating a patient about the treatment required and its consequences. (Royal College of Nursing, 2003) Nursing uses a particular mode of intervention - Nursing interventions are aimed at empowering people, and helping them to achieve, maintain or recover independence from their illnesses. The nursing approach to treatment is a comprehensive one which is inclusive of intellectual, physical, emotional and moral process. Nursing Diagnosis involves assessing the patient and developing a plan of care. This is followed by the evaluation of success of the plan and looking into the revision it requires. (Kathy Quan, 2006) Nursing has a focus - The focus of nursing is on treating the person as a whole and the human response in the event of a difficult situation (illness), rather than a particular aspect of the person or a particular pathological condition. (American Nursing Association, 1995) Nursing has a set of ethical values - The nursing practice is governed by a set of ethical values.. The nursing codes of ethics are expressed in written form and supported by a system of professional regulation. Thus, nurses are individually accountable and responsible for their actions. (American Nursing Association, 2006) Nursing is about commitment to a partnership - A nurse works in partnership with their patients, the family members of the patient and the caretakers of the patient. They collaborate with others as members of a multi-disciplinary team. (American Nursing Association, 1995). Purpose of this study The purpose of this study is the need for adopting how Cognitive Behaviour Therapy (CBT) is applied in nursing practice, reason being that cognitive therapy is different from other models of psychotherapy because it is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient (Beck, et al 1986). Following is the list of objective of this research: Understand what is CBT How is CBT useful in nursing? Looking into CBT techniques and how it helps to improve patient’s health How CBT helps to improve community care of patients? Looking into a case study to understand the actual working of CBT A look at how Cognitive Behaviour Therapy (CBT) is applied in nursing practice CBT is a form of therapy in which the nurse engages the patient in a collaborative manner for the purpose of examining how the person understands the world around them. Cognitive therapy is different from other models of psychotherapy because it is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient (Beck, et al 1986) The cognitive behavioural therapist evaluates the process by which the patient acts based on their understanding of the situation around them. The set of belief and understanding that a patient has is challenged by the nurse using a series of behavioural or cognitive experiments. The purpose in doing this is to bring about a gradual change in the thinking, behaviour and interaction of the patient with their surrounding environment. Thus, CBT is a psychotherapeutic model where the nurse uses the process of guided discovery, to help the patient bring out those beliefs and idea which determine how they rend to think and behave currently. On unfolding the existing belief system, the nurse helps the patient to experiment with alternative explanations and responses so that the patient can understand through evidence about their faulty reasoning. The idea behind CBT is based on treatment plans, which have been tested. They help the nurse by providing vital guidance through each action, session, and overall plan of care. “This psychotherapeutic model is one which have been most researched and it show considerable effectiveness in the treatment of a wide range of emotional and behavioural problems. CBT has show empirical efficacy in treating a range of illness like tinnitus” (Andersson G, et al 2005 pg 671-675), chronic pain disorders, premenstrual dysphonic disorder and sleep disturbances. It has also proven itself in the area of treating mental illness such as depression, anxiety, and panic disorders (Heldt E, et al 2006, pg 657-665), eating disorders, personality disorders, substance abuse disorders, marital problems, post traumatic stress disorder, self-injurious behaviours (Tyrer et al., 2003 pg 969-976), obsessive compulsive disorder and schizophrenic symptom reduction. Advanced practice psychiatric nurses (APPNs) are in a unique position to coordinate the physical, psychiatric, and social theory into true holistic care for the patients using the highest standards of empirically supported treatment. Given the evidence supporting CBT, it makes sense that APPNs become adept in the use of this psychotherapeutic method. Another aspect that can be incorporated in the use of CBT is schema therapy (ST, which is an expansion, extension, and revision of the classic CBT. Dr. Jeffrey Young, who developed this therapy, states that "in comparison with standard cognitive therapy, ST probes more deeply into the childhood origins of distorted thinking, relies more on imagery and emotion-focused techniques." (Young et al 2003) The principles of Cognitive Behavioural Therapy (CBT) CBT is guided by certain principles. These include the principle of Cognitive Set and Cognitive Shift. In Cognitive Set, each individual shows a typical response to their environment. Whenever the individual confronts any scenario, they have to assimilate information, process the information, analyze the information and then make a response which according to them is appropriate. According to CBT, thoughts, behaviours and feelings interact to form a cognitive "set." If any changes are made to one area of the "set," the remaining components will also change. The role of the nurse is to interact with the patient in such a way so as to find out the patient’s cognitive "set". In the process of doing so, they will determine, if change is warranted, and if so, they will establish outcome goals that are reasonable, attainable, and measurable. (Freeman, SM 2006) The role of the nurse is brining about such changes is one wherein they act as a coach, mentor, or guide. They provide necessary training to impart skills to the patient, to cope with their illness (Beck & Freeman 1990). They design experiments, in collaboration with the patient, in which the patient succeeds from undertaking the experiment so as to boost the patient’s confidence levels. Thus, the techniques used by the nurse include collaborative empiricism and guided discover in order to help the patient to change assumptions and other cognitive errors, because of which the patient is not able to behave normally to their surroundings. In the case of Cognitive Shift, the patient’s detrimental mental health caused by anxiety or depressive, results in their cognitive set becoming distorted so much s they take on primitive or reactionary behaviours. The net results of such skewing is a cognitive shift as it introduces I undesired bias into the interpretations, inferences, and coding mechanisms of the patient, which further leads to distorted cognitions. Understanding this shift help the nurse to understand the origin of a patient’s problem and provide assistance according to their inferences from the shift. (Freeman, 2006) Development of cognitive behaviour therapy Cognitive behaviour therapy has evolved from the work of Aaron T. Beck. He has done substantial work in the arena of CBT, by conducting systematic studies on depression and suicidal thinking using structured cognitive therapy. His studies were shaped by clear guidelines and specific procedures. In the 1970’s the process of apply behavioural techniques to cognitive theories and strategies was carried out by researchers. Earlier, traditional behavioural experiments were used to shape only measurable behaviours and there was no importance given to the use of the cognitive processes to understand the behavioural and emotional changes. Once the importance of using cognitive techniques was understood, it became important to that nursing interventions target all three foci (cognition, behaviour, and emotion) in order to effect sustainable changes, cognition being the pivotal point. This is because cognitive therapy differs significantly from other models of psychotherapy in that it "is a collaborative process of empirical investigation, reality testing, and problem solving between the therapist and the patient”. (Beck et al, 1986) Following are the techniques used in cognitive behaviour therapy: The nurse uses a set of cognitive behaviour techniques to help patients understand how to deal with their emotional problems. (Freeman, SM 2006). Following is a list of such techniques used: Downward Arrow – Using this technique, the patient is assisted in understanding the logic and sequence of their thought. The nurse takes a particular assumption of the patient and then asks, "If this is true, then what happens, so that the patient understands the results of what they are assuming?”. Idiosyncratic Meaning – This techniques is used by the nurse to helps the patient, the terms and statements which they use. This is done in order to make it clear to the patient about what is their perceived reality. Labelling of Distortions – Through this method the nurse identifies those automatic thoughts in the patient which are "dysfunctional or irrational. Taking an example here, the nurse may simply stop the patient’s narrative in the middle, through a question, "did you mean you were 'simply without proper clothes and food because' or ‘you were really impoverished?. This helps the patient to understand the images their thought evoke and if these images are in fact the reality of the situation. Questioning the Evidence – This process enables the patient to ask themselves questions related to what they perceive and the consequences of their perceptions. It helps them to uncover the reality or truth behind their assumptions. Examining Options and Alternatives – Using this technique, the patient is made aware of the other option they can adopt. This will help them to develop option in their mind rather than be focused on only "only one way" thinking. Reattribution – This helps patient who assume most of the blame of their problems. They learn how to reposition blame on other people who are responsible for their current situation so that the stress of their disorder reduces. Decatastrophising – This technique is particularly useful for people, who are too anxious because they are much focused on negative possible outcome of any given situation. This technique helps them to face realities better, by examining the "worst possible outcome" and developing a plan of action. Following are the techniques used in behaviour therapy The nurse uses a set of behaviour therapy techniques to help a patient to understand how to deal with their emotional problems. (Freeman, SM 2006). Following is a list of such techniques used. Assertiveness Training –In this techniques using a process of role play, the nurse to help the patient to understand the behaviours which they must adopt. The patient will go through a series of experiments, with the complexity of the experiment increasing every time so that the new behaviour which the patient needs to adopt is internalized. Behavioural Rehearsal – Here, the require behaviour is rehearsed so that the patient come to understand and fully adopt the more effective responses and styles. Graded Task Assignments – Here, the nurse asks the patient to undergo certain assignments, by which they uncover their fears or thought which producing anxiety. As the sessions progress, the complexity of these assignment also increases. Guided Relaxation and Meditation – her the nurse guides the patient to learn methods such as measured breathing, relaxation training, meditation by which they relax themselves and by which reduces the autonomic nervous system responses to anxiety, and other techniques. Social Skills Training – The nurse reviews the social skills of the patient to analyze wrong patterns and to enable them to learn those social skills which will help them to succeed in life. Shame-Attacking Exercises – In this technique, patient undertakes behavioural experiments, which helps them to perceive their concern for what others think of them. An exercise is developed and put to test to find out of a particular perception is really true, to help the patient differentiate between "feeling" and "fact" to move past shame-based behaviours. Home work – This behaviour therapy techniques is the hall mark of CBT, wherein assignments are given to the patient which they have to carry out in their natural environment and they are also worked upon between sessions Case study: Improving community care of patient with serious mental illness using CBT Let’s take the case of community setting and see how CBT can be implemented in a setting wherein there are seriously mentally ill patients. The setting in which mental health nurses and APNs in the community work primarily are case management teams, assertive community treatment (ACT) teams, partial hospitalisation programs and outpatient clinics. Since nurses have training on biological, psychological, and social aspects of illnesses, they are largely preferred in these areas. Taking CBT training that focuses on three areas can enhance the knowledge and skills. These include improving medication adherence, promoting positive health and wellness and engaging families. The training a psychiatric nurse undergoes in thee areas will help them to is to improve the overall response rates for patient who have a serious mental illness and helps them in their recovery. Here’s a look at how CT’s aid nurses in these three areas of training. (Kingdon D and Turkington D, 2005) Improving Medication Adherence - It’s often been noticed that the main reason why a person has a relapse into a problem is because, they do not seriously adhere to taking medicines. In this context, the nurse must, educate patients about the effects of medications. It is their responsibility to create systems, which track the adherence to medication and note down the adverse effects as well. This is because according to CBT, not taking the medication is one of the main reason automatic thoughts and dysfunctional beliefs arising. It tends to burden the cognitive capacity of vulnerable individuals. Partial adherence and non-adherence are very common in SMI and are the primary reason for relapses and hospitalisations. Administering medications, educating patients about the effects of medications, creating systems for medication adherence (eg, "Medi Planners," containers for sorting and tracking medications) and monitoring for therapeutic and adverse effects are critical tasks central to the profession for a nurse in any setting. The reason why patients with serious mental illness do not adjure to taking medication is because, they underestimate benefits of medication therapy or they overestimate the side effects it can cause. They may be holding beliefs that the mediation is really not required and that it is very harmful or part of some conspiracy. (Pinninti NR et al, 2005) Dysfunctional beliefs about medication can be assessed by enquiring in a gentle and non-threatening manner the positive and negative thoughts that individuals have about their medication. Questions such as, "Did you have any thoughts about stopping your medication recently?" or "What do you consider the downside of taking medication?" can help the therapist understand the automatic thoughts about medication. At this point the nurse must teach the patient about the actions and side effects of their medications to the patient. Medication use for most individuals is meaningless unless it is tied into their life goals. CBT helps reframe dysfunctional beliefs about medication, connects medication adherence with life goals, and thereby promotes long-term adherence. Promoting Health and Wellness - In these areas, the nurse seeks to remove a sense of paranoia in the patient which arise because of lack of trust in physicians, and dysfunctional beliefs about physical illnesses and preventive care. Patient with serious mental illness experience health problems because of their negative beliefs and attitude towards using medication. They have paranoia about mediation and lack of trust in physicians, and dysfunctional beliefs about physical illnesses and preventive care. This attitude can seriously mar them from consulting a doctor about their illnesses. They may also be in a situation wherein they have poor access to primary care providers and specialists due to inadequate health insurance coverage. There is also this fear of fear of stigma and bias which prevents many patients who have a serious mental illness from accessing care. They experience bad health because of poor dietary habits, sedentary lifestyle and high incidence of substance abuse or smoking of cigarettes. Using CBT as a tool, the role of the nurse here is to remove such problems through counselling on the consequence of adopting negative ideas dysfunctional and delusional beliefs. (Pinninti et al, 2005) Engaging families – It’s been noted that most patients who have a serious mental illness live with their family. They are also seen to keep in touch with their relatives. In such situation wherein, family relationships are supportive, there is a better chance for the patient to take their medication regularly, reduce the incident of hospitalisations, and improve functioning. However, one problem with patient who have a serious mental illness, is that in course of time their family may feel burdened by seeing them in a poor mental state. (Lambert et al, 2003) Through the use of CBT, a nurse can help a patient’s family to cope with the problem f having a family member with a serious medical problem. The nurse can educate them on how to deal with the patient in order to reduce family tension, hospitalizations, and risk of relapse by up to 50%. Case study: Treatment of Depression with CBT Anita is a 35 year-old married woman who has been diagnosed with breast cancer. She has undergone a series of chemotherapy treatments following a mastectomy with breast reconstruction. Anita makes an appointment with her nurse practitioner, Linda to evaluate the depression because she is difficulty in falling asleep, waking up in the morning, showing tearfulness, lack of energy or motivation, and has a sense of hopelessness, and helplessness. When her nurse Linda, evaluates her for medical explanations, she finds that all serum levels are normal, but the symptom of anaemia, is something which is common for individuals undergoing chemotherapy. She prepares a list of point for which she wants to evaluate Anita and this list includes the following point: A introspect of Anita’s mood to find out what she is feeling about the recently occurred events. Work together with Anita to set an agenda for their meeting and making sure that discussion of psychotherapy and medication options are part of the agenda. Look into the results of Anita’s medical evaluation. Discuss those issues and views, which Anita find disturbing as mentioned in their agenda. Introduce or review specific skills to help Anita understand who she is feeling and how she perceives herself. Develop an assignment and also look into those points which may interfere with homework completion. Help Anita summarize the main points of their meeting and the conclusion they have arrived at. Using the Socratic dialogue technique, (Beck et al, 1990), Linda frames a set of questions, which she wants to ask Anita. The purpose behind these questions is to help Anita understand the meaning she is attaching to her experiences and the way she understands herself as an individual, but this is done in a very gentle, yet persistent manner. Following is a sample of some of the questions about her session. What are the activities that you have enjoyed in the past? What activities give you a sense of pleasure? Is it possible to engage in (name of activity) part of the time, or to a smaller degree? What might be the consequence of engaging in (name of activity) to this degree? How can you start engaging in this activity? From the discussion what merged was that Anita had a very low self-esteem because of the disfigurement caused by her surgery. The session helped Anita to find out what she likes to do and helped her to look at the means suggested by the doctor to cover up for the surgery disfigurement in a positive angle. Advantages of using CBT In the case of patients who are trapped between two options CBT help them to assess the advantages and disadvantages, to enable them to develop alternative perspectives. This helps them to break away from the "all-or-nothing" mindset and permits a more balanced view of the situation. The use of the Paradox or Exaggeration technique in CBT enables the nurse to help a patient who has been holding exaggerated view pint to understand the reality of those view points. (Freeman, SM 2006) One of the biggest advantages which CBT give a patient is they learn techniques by which they can turn what appears to be a negative situation to their advantage. For example, being turned down for a job may open the individual up for more attractive possibilities that they had not investigated. One of the most important aspects of CBT is ST. Through ST Cognitive behavioural therapists try to change schemas which are no longer useful or which are basically maladaptive. Schemas developed during childhood are early schemas and such schemas are more resistant to change than schemas that develop later in life. Such type of schemas is early maladaptive schema and they are explored and modified by the process of giving ST treatment. (Young et al, 2002) The use of cognitive rehearsals in CBT helps a patient to making a behavioural change and to "practice" the new behaviour through visualization and discussion. For example, they may learn to practice assertiveness in a mirror or "talking through" a confrontation out loud prior to actually following through with the conversation. The CBT makes use of automatic thought record (ATR), in which the patient has to work out assignment of what he or she learns in the therapy session. The individual completes the columns identifying a troubling situation, resulting emotion, and thoughts associated with both. The therapist and patient work on clarification and development of "rational" responses in order to debate or challenge the original reaction (Freeman, SM 2006) Conclusion CBT is a process of engaging a patient in a collaborative manner for the purpose of finding out how the patient understands and deals with the world around them (Beck et al, 1986). CBT assumes a person behaves, thinks, and feels about a certain situation depending on how they interpret the situation. CBT uses specific techniques to help people learn to recognise the way that their thoughts, feelings, and subsequent behaviours interact. The nurse focuses on the mental distortions of the patient and points out this process to the patient. The nurse further in collaboration with the patient helps the patient to exploring the factual basis of the cognitive style. CBT also helps a nurse to understand the processes by which a patient acts on these behaviours. In the process of CBT the nurse assumes the role of being a coach, mentor, or guide for the patient. They provide training for the skills that the patient has to develop and they also design appropriate experiments with high likelihood for success to enable the patient to adopt new attitudes better. They identify those schemas which are no longer useful or are maladaptive to the patient and through counselling help the patients to remove such schemas which they have stored in their memory. 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