Cognitive Behavioural Therapy and Psychosocial Interventions - Essay Example

Cognitive Behavioural Therapy and Psychosocial Interventions Introduction This essay is in two parts. In the first part, it is focused on the wider body of literature on psychosocial interventions in severe and enduring mental illness including the barriers to implementation and how they can be surmounted in practice, particularly with the advancement of Cognitive Behavioural Therapy (CBT). For the purpose of this essay the term ‘psychosis’ will refer to a range of symptoms that are found within the diagnostic categories of schizophreniform illness (Gregory, 1987).  The second part is focused on direct service user involvement, demonstrating the principles of engagement, assessment, formulation, intervention and coping enhancement as tools for psychosocial intervention. The application of these tools will be demonstrated by a case study of a service user with psychosis, in conjunction with evaluation and reflection of the care delivered. Cognitive Behavioural Therapy and Psychosocial Interventions During the 1980’s the Cognitive Therapist joined forces with the Behaviour Therapist to modify people’s inaccurate beliefs. The two therapies merged to work hand in hand, which led to much research being conducted in recent years. This helped to advocate the development of cognitive-behavioural interventions for psychosis (Haddock & Slade, 1996).  Psychosocial techniques were developed to help modify medication resistant experiences and claim to be the most promising advancement in the treatment of schizophrenia for many years (Kingdon & Tukington, 1994).  The intention was to move closer towards directing therapies for specific symptoms. This in turn would help the service users normalise or accept their experiences, which otherwise would be exceptionally disturbing. The main assumption behind psychosocial interventions is that, psychological difficulties depend on how people think and interpret events (cognition), how people respond to these events (behaviour), and how it makes them feel (emotions) (Kinderman & Cooke, 2000).  In other words, correlations and links are made between the service user’s feelings and the pattern of thinking which underpin the distress they experience.  This therefore suggests that, the way people feel about a situation or experience depends on what they think about it and how they interpret (Nelson, 1997). In the context of severe and enduring mental illness, the introduction of psychosocial interventions allow us to work with service users who have difficulties with their thoughts, making illogical associations and developing false and sometimes bizarre explanations for their feelings, this causes poor social functioning or withdrawal.  The method used with psychosis strengthens the service user’s logical reasoning ability against their intuitive feelings, for example, it encourages a split between “I feel/believe/hear”.  Standards to psychosocial interventions include logical reasoning, evidence for and against distressing beliefs, reality testing and generating alternative explanations (Kingdon & Tukington, 1994). Psychosocial Interventions in Psychosis Positive symptoms of psychosis such as hallucinations are often distressing experiences because of the service user’s perception of whom or what is responsible.  The use of psychosocial interventions can encourage service users to challenge commanding voices in a collaborative manner.  For example, in order to limit the power of command auditory hallucinations which threaten bodily harm if the service user intentionally stops the occurrence of an obsessive thought, the service user may develop counter thoughts (Kingdon & Tukington, 1994).  An example of this may be thoughts such as: “Why should I do that? You are only a voice – you are powerless: there is no way a voice can bring me physical harm” and “I did not do what you commanded last night for an hour and there was no consequence”.  This will help towards empowering the service user to have more control over the symptoms whilst improving self-confidence in dealing with similar future incidents.  If, say for example, critical voices were to accuse the service user of not being normal, who then experiences a behavioural consequence of becoming socially withdrawn, the voices themselves can be challenged to produce evidence to back up this statement. A failure to produce such evidence may render the voices unworthy and mute, which may then help to increase the service user’s level of social functioning.  This type of intervention to modify delusional beliefs about the origin of voice may help to reduce the distress they cause and help to a re-evaluation and re-interpretation of psychotic experiences (Nelson, 1997).  Given that delusional beliefs can be held very firmly, most literature on psychosocial interventions warn that, all challenges need to be proceeded slowly and cautiously and technique is used to challenge the evidence supporting the distressing belief rather than the belief itself (Gamble & Brennan, 2000).  The nurse then works with the service user’s to help them identify thoughts and behaviours that are relevant to their problem and subsequently teaches them to carry out the whole thought process independently.  The proposal behind this is that, when service users learn to challenge their own thoughts, armed with the knowledge imparted by the nurse, they will eventually be able to use the skills on their own.  In addition, service users will learn new behaviours and problem solving skills so that they can interpret their thoughts and behaviours in more rational ways.  Educating service users to understand how and what they think in the moment is therefore an important part of the therapeutic process (Lam & Gale, 2000).  This has brought about a psychological understanding and seeks to support service users in developing their own understanding of the nature of their illness and what is most likely to help them manage it. Effectiveness of Psychosocial Interventions in Recovery Countless service users have entered the trial of psychosocial interventions in practice. The short and medium term data suggest that CBT may decrease relapse/readmission (Effective Health Care Bulletin). Some of the well-known randomised control trial studies on the efficacy of CBT on psychosis against standard care and supportive counselling, which show reasonable consistency across studies: see Tarrier (1998); Drury (1996); Garety (1996) and Kemp (1996).  In the Cochrane’s Database review (2000), these studies are evaluated.  The data show that the group who received cognitive behavioural intervention over a period of 9 months including a follow up period had significantly depicted superior improvements in measures of both positive and negative symptoms compared to those in the standard care.  Further, differences are observed favouring CBT over standard care.  CBT helped to reduce risk of relapse by 54% and increase interpersonal functioning while the standard care group were characterised by serious symptomatology and impaired functions, requiring medical treatment.  The studies also report the beneficial effects of these interventions by improving compliance and insight. The recent available evidence strongly supports the use of CBT in the treatment of psychotic symptoms in early stage and in long-term illness where resistance to medication is depicted.  These studies also show that CBT has sustainable effect even after the completion of active treatment. Research has also focused on using CBT in family interventions and reports show a significant improvement in families’ problem solving skills and reduction in clinical, social and family morbidity (Kuipers et al., 1992). While the efficacy of CBT is unquestionably well documented, the general disability of the data in the studies, however, raises some concerns.  Often established controlled studies, lack an adequate breakdown of sample characteristics in terms of race and culture. Furthermore, discussion is also lacking on the details as to the way in which symptoms improved or social functioning enhanced in behavioural terms in relation to social context. As a result, it is difficult to deduce factors, other than cognitive behavioural interventions, which may altogether influence change.  The main stay is a quantitative data presentation rather than qualitative.  Given that the population in the UK is increasingly multi-cultural and diverse, including people from various cultural, racial and spiritual backgrounds (Fernandos, 1995; Adams et al.,1998), how inclusive are these studies of different minority ethnic groups?  Given that, it is a well documented fact that many ethnic groups are often not referred to psychotherapy due to the inherent stereotype view held in psychology that they are not psychologically sound (Robinson, 1995), has widely acknowledged promising usage of CBT with a difference. Some black communities are unable to articulate distress adequately in the English language or have no direct meaning in their own language for anxiety or feelings (Kareem & Littlewood, 1992; Hussain 2000), how does then one carry out collaborative work when the link between emotion and thought are attempted to ‘strengthen the patient’s logical reasoning’?  Can it be argued that CBT is likely to be most effective with the indigenous population, while it has minimum usage with other groups?  Especially so, say, for some parts of the Muslim community (see Badri, 2000; Hussain, 2000), who may not culturally view life or conceptualise health and illness in separate bits - as in CBT’s ‘rational’ or ‘thinking’ terms. Furthermore, Zimmermann et al (2005) state that compared to other adjunctive measures, CBT demonstrated significant reduction in positive symptoms particularly for clients experiencing an acute episode. However, the inclusion of the Drury et al (1996a) study in the meta-analyses may have, according to Zimmermann et al (2005) produced an over-estimation of the effect size in acutely ill clients. Although the studies included in the assignment have been identified benefits of cognitive behavioural interventions, in support of the National Institute of Clinical Excellence (NICE), (2002) schizophrenia guidelines that CBT should be routinely available for individuals experiencing schizophrenia. Further, studies need to be undertaken in order to confirm the efficacy of the interventions, especially as a vacuum exists between the NICE recommendation and the services provided in reality (Brooker and Brabban 2006). Critically analysing, the evidence-base derived from the studies implicate that the study conducted by Lewis et al (2005) was the most rigorous and that by Startup et al (2004) is more relevant to clinical practice. Recovery has become a core concept in contemporary mental health practice and has taken on some reasonably specific meaning. Anthony (2003) called recovery to be the ‘guiding vision’ for mental health services. Section B Module title: Psychosocial Interventions (PSI) in the Assessment and Treatment of Severe and Enduring Mental Illness Psychosocial Interventions in Clinical Practice (Case Study) Mr. X has a history of considerable antisocial conduct. He is a forty three years old man who has been nursed within this inpatient facility for almost three years. Mr. X was admitted from Her Majesty’s Prison Service following ruling from the Crown Court that he requires a period of assessment after the false imprisonment of a business associate. Mr. X Perkins presented with underlying psychotic symptoms with principal delusions of grandeur and unstable in his mood. His view is that other people (staff, visitors, family and the common public) are constantly ‘changing’ in their appearance to confirm that he is in fact God. Despite this, he is able to forge a level of therapeutic alliance with some staff members, in particular middle-aged male staff members. He is verbally abusive and with his large physical stature is intimidating towards the other service users on the ward and staff members. His abuse is usually targeted towards his wife when she visits him and tells him bad news about his upcoming court case (the information is true, although he believes she is not helping him to get out of the hospital and subsequently from the prison). The author is a registered mental health nurse and commenced employment in the ward a few weeks before the admission of Mr. X. The author has developed a level of therapeutic relationship with Mr. X, although this is superseded by Mr. X’ regular changes in mood and mental state. Initially in the engagement stage, the interventions focused on developing rapport by showing an interest to Mr. X’s experience of living with a psychotic illness (Nelson, 1997).  Given the assumption that, I was likely to be viewed by Mr. X as part of the psychiatric system that is demeaning, the aim was to demonstrate an openness and honesty about my role and bring to the session a sense a difference from the ward staff.  This was a way in, in an attempt to provide a rationale for the CBT work and developing trust, which helps to promote a collaborative partnership between the therapist and patient (Thompson, 1996).  A reciprocal discussion with Mr. X on how the referral came about, what his expectations were, explanation on what I had to offer and an exploration of his feelings on considering new ways of dealing with psychotic symptoms (Gamble & Brennan, 2000), was further useful for the engagement process. Mr. X’s clinical symptoms were assessed using the KGV (Krawieka, Goldberg and Vaughn, 1977) symptom scale, which focuses on five areas including anxiety, depression, suicidal thoughts and behaviours, elevated moods, hallucinations and delusions.  The use of direct and somewhat intrusive questioning in the KVG, found Mr. X to score significantly between three and four for anxiety, delusions and between two and three for hallucination in comparison to the other symptoms.  It was clear that Mr. X was hearing critical voices of a debilitating nature a number of times in a day, which was making him feel confused, frightened and restless.  Given this preoccupation, the anticipation of panic and powerlessness once exposed to any environment different from his flat had also stopped him from going outside regularly. This was making him increasingly distressed and house bound.  Assessment is a process that elicits the presence of disease or vulnerability and level of severity in symptoms (Birchwood & Tarrier, 1992).  The gathered information provides the basis to develop a plan for suitability of treatment, identifies problems and strengths and agree upon priorities and goals (Gamble & Brennan, 2000; Nelson, 1997). While the assessment helped to form a picture of Mr. X’s problem and suitability for CBT, it also provided a scope for further work on his coping skills.  Given the assumption that, a person may feel reluctant to give up a particular way of coping, as this may be the only means of control (Gamble & Brennan, 2000), the exploration was collaborative.  It was found that Mr. X had a faulty way of coping with his critical voices.  When the voices start commanding he shouts back at them in an aggressive and loud manner. While this gives him temporary relief when the voices stop, leaving Mr. X feel safe, his neighbours would react either by knocking on his door or calling the police. This would make him feel that people are against him and further power and trigger the cycle of critical voices.  The adoption of Coping Strategy Enhancement (Birchwood & Tarrier, 1994) and Romme & Escher’s (1989) ideas on coping strategies were used.  The idea was to build on Mr. X’s existing coping method and introduce an alternative.  We agreed upon distraction as a coping strategy.  The plan was for Mr. X to listen to music or carryout breathing exercises when the critical voice appear and to start interacting with them by telling them to go away instead of shouting at them. This plan used over a period of time seemed to have reduced the psychological arousal and helped him gain maximum usage of these strategies in controlling the symptom. Gibbs’ model of reflection is used to present this study. The model depicts: Gibbs' model of reflection (1988) (Gibbs, 1988) Description In the case study presented, Mr. X is facing problem of remoteness, on evaluating the case it was found that Mr. X has some inherent problem may be because of his previous experience or because of some happenings in the past. These could be social abuse or financial problems that have to be analysed in order to treat him psychologically rather than medically. The case depicts that Mr. X needs and demands great amount of care. The reflection model adopted to present the case needs full co-operation of the patient and also his consent for the accomplishment of the task in the form of Mr. X’s health and normal behaviour so it is imperative that we must focus upon the situation(s) that ignite Mr. X and motivate Mr. X to try to be optimistic in all situations and should come out of the feeling that everyone is against him. Reflection The author is trying to achieve a congenial behaviour of Mr. X and improvement in his social performance and interactions. The author’s actions are obvious and need of the situation he wants that Mr. X should behave in a cognitive manner and should come out of his hallucinations and voices and live a realistic life. These actions are directed to have positive consequences which may take some time but the author must be patient for the same. The patients’ family support to cope with the problem is very imperative especially his wife’s role to have a congenial and no conflict atmosphere at home. The author must have one-to-one relationship with the patient paying attention to all the demands and must give ear to all his grievances. This is very vital to cope with the psychological bindings of Mr. X. Behaviour of Mr. X is not accepted by the civilized society and there is a great deal of fear amongst the neighbours also and they become over protective for their families. An understanding from them is desired. The author must have a dialogue and discussion regarding the support of the neighbours. This will definitely make the patient feel confident about his moves in the society. It is the responsibility of the neighbours and acquaintances not to press the hot buttons of Mr. X or reminding him about any such incidence that ignites his anti-social behaviour. The society must talk constructive thoughts of progressive temperaments and must try to involve Mr. X in social happenings asking him his point of view and judgements. The author must discuss these issues with the people around the patient. Influencing factors The decision making is very important when dealing the patients like Mr. X. The patients reliability and trust on the caretaker must be kept in mind. The patient must have full faith and must confide on the caretaker so that he can share his feelings and expressions. This aids in sooner recovery and help to cope with the situations. According to Gibbs theory of reflection, reflection is the most imperative human activity in which people recapture their experience, they think about and mull it over and also evaluate it. It is very important phase of learning. The author must apply his past experience of tackling with the patient, keeping in view that individual’s nature varies all over the world the author is desired to apply his experience and intellectual and affective activities to develop new understandings and appreciations for the patient. Alternative strategies The way author has dealt is completely satisfying in the terms of CBT. The other most desirable approach is to build the lost faith and confidence in the patient to fight all odds and feel confident about his actions and motives. The caretaker must appreciate the patient even in small accomplishments. This will be a great step in the direction of coping with the distress in the patient. It will certainly bring positive consequences in the patients attitude, outlook and behaviour and aids in the success of the caretaker. Learning Kolb's Learning Cycle (1984) (Kolb 1984) The Kolb’s learning cycle is based on observation and reflections. The experience gained in treating each and every patient to the utmost satisfaction of the caretaker is the biggest accomplishment. In this case the keen observation of the caretaker in tackling day-to-day tasks by the patient is imperative. Every patient is different in nature depending on the environment, upbringing and socio-economic values still some similarities can be sorted out and an abstract of the nature can be formulated. This can be well implemented using the concrete experience about the patients nature and conduct. The author must feel satisfied in view of the fact that he has taken effective actions and his way of knowing the patient and tackling with them even in the tough situations with calm attitude Conclusion Studies highlighted in this essay show considerable strength in supporting claims of efficacy that CBT can work and does help to reduce and control symptoms of psychosis.  “Some applications of cognitive behaviour therapy remain highly experimental and require considerable more research and more sophisticated theoretical models.  Without this increased understanding of what works for whom, and why, we should remain cautious of overenthusiastic claims for efficacy and of the clumsy application of generic cognitive behavioural theory being made to fit increasingly diverse disorders”. References 1. Adams R, Dominelli L & Payne M (1998), Social Work: Theme, Issues and critical debates, Macmillan, UK 2. 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