Examining nurse's use of cognitive behaviour therapy: cognitive behaviour therapy is an effective treatment for those with mental health problems. New research, involving six community mental health nurses, looks at some of the issues which help and hinder the use of this therapy.
Cognitive behaviour therapy (CBT) is a proven method of psychotherapy that proposes it is not events themselves that cause anxiety and maladaptive responses, but rather people's expectations and interpretations of these events. It suggests maladaptive behaviours can be altered by dealing directly with a person's thoughts and beliefs. (1) CBT is a generic term that encompasses a number of approaches, specifically cognitive therapy (CT) and rational emotive behaviour therapy (REBT).
Fundamental to quality mental health nursing is the establishment of a "partnership" between the nurse and the client. (2) The nursing process and CBT have a lot in common--both are client centered and strongly emphasise mutuality. The client is involved in defining the problem, identifying goals, formulating treatment strategies and evaluating processes. CBT is educational and skill building, rather than curative, with the therapist taking a facilitative role. There are presently two funded CBT training programmes in New Zealand. These 24-week postgraduate programmes are specifically designed for practising mental health professionals. They are clinically based and students entering them must be registered health professionals, employed full-time within a publicly-funded mental health service. (3)
A review of the literature looking at psychotic illness management and recovery consistently found that CBT is more effective than supportive counselling or standard care in reducing the severity of psychotic symptoms. (4) The use of anti-depressant medication and CBT are effective treatment options for depression and are recommended by clinical practice guidelines. (5)
Research has found CBT is one of the most cost-effective treatment options for mental disorders and is presently under utilised. (6) Another research study discussed the application of CBT in the treatment of clients with schizophrenia and the subsequent implications for mental health nursing. (7) It found that because of their continual direct client contact, mental health nurses are the ideal practitioners to deliver CBT, and concluded CBT should be aggressively integrated into the role of a community mental health nurse (CMHN). (7)
Only one piece of New Zealand research concerning enablers and barriers to dissemination of CBT strategies and techniques in our mental health service, was sourced. (8) This research was multi-disciplinary and, due to the small sample of graduates, the survey responses could not be compared across the different professional groups. No New Zealand research specifically around the impact of CBT training on the clinical practice of mental health nurses was sourced.
A group of researchers has identified why dissemination of the evidence-based practice of CBT, in Britain, has not progressed. (9) Reasons cited included absence of appropriate knowledge and/or clinical skills; characteristics of the organisation or workplace, which constrained new developments/practices, and, maybe, the realisation that new clinical techniques were more difficult to learn and implement than initially thought.
The aim of this qualitative study was to explore in-depth the experiences of CHMNs' use of CBT as a treatment modality. Purposeful sampling was considered the most appropriate means by which to gather participants. Ethical approval and legal advice regarding this research study was sought and gained from the Central Regional Ethics Committee and the Eastern Institute of Technology's Research Approval Committee.
Data was collected through audiotaped interviews. The individual interviews were approximately one hour and were focused and semi-structured through the use of three guiding questions/prompts. They were:
1) Can you tell me about your experiences of using CBT in your role as a CMHN?
2) What are the factors that promote and hinder your use of CBT in your role as a CMHN?
3) Can you tell me about the CBT/REBT training you received?
The data obtained from the interviews was transcribed and the interview notes were read and re-read to gain familiarity with the data. A categorisation scheme was developed and corresponding codes were used to sort and organise the data. The patterns and structure that connected the thematic categories were then searched for and identified. (10)
Six female CMHNs, aged between 20-69, were interviewed. The participants identified as New Zealand European, New Zealander and British. Five had completed CBT training, with the time since completion of that training ranging from five years to six months. The sixth participant had completed REBT training ten years ago. All were currently employed in district health boards (DHBs) as CMHNs and the time in their current roles ranged from three to nine years. Pseudonyms have been used to maintain their anonymity.
Four major themes were developed from analysis of the interviews.
Theme 1: Nursing using cognitive behaviour therapy: The participants talked about their experiences of using CBT with different client groups. Ellen talked about her experiences of using CBT with clients experiencing "voices" She recognised and valued the CBT approach and stance of not saying "the voices have to go" but reframing the experience: "So they're there. Why is that so distressing to you? Why do you have to listen to them? Would you listen to your mother when she tells you to dean your room and you don't want to? So why would you listen to a voice that's saying you must hurt yourself?"
Generally the participants felt the chronicity of a client was not a key factor in the effectiveness of CBT. "I've had some clients who have been quite new [to EMH services] and some who've been around for many years. There was this woman who's been in the "system'-for about eight years ... the people who were working with her were getting a bit stuck ... so we talked about it and said, shall we try some CBT, and so that's sort of moving her along now. " (Eva)
Ellen, who completed her CBT training five years ago, talked about working with clients in whatever style suited them best. "I know every person is different and a different approach is going to work--so for some people who are very cognitively minded you know the cognitive part of CBT is going to work, and with someone who is very depressed you know that the more behavioural parts of that approach may work better."
A number of the participants felt the title CMHN did not accurately reflect their training and work. They were all proud of their role as CB therapists and felt they were actively doing "therapy" with their clients and their title did not reflect this "therapeutic" role. Amelia explained: "I wanted to get my job title changed or added to, Jar example CBT nurse therapist/ specialist etc, but I was told that unless I have done a masters degree in counselling therapy I have no right to call myself a therapist or have a title that reflects "therapist' in any way. I'm not sure what else I do with clients if I'm not a "therapist" in one way or another. I'm not sure if that's a DHB policy or whether it's just "personal" to the manager I spoke to re changing my title. It was looking like it was going to be a huge project to continue to seek out a new title and I didn't think it was really going to be worth it. That manager I went to about this is not a "nurse"--whether that impacted on her decision or not--I'm not sure."
Theme 2: Positive influences: The participants identified a number of factors that positively influenced their use of CBT in their role as CMHNs. For Eva, the key promoter of her use of CBT was the fact she knew it worked. "Um, I guess it's the-fact that I know it's effective ... it [CBT] has good efficacy ... I mean, I guess in the end the plus is that it works."
Amelia said CBT allowed her to work with clients in the way she wanted to work. "I'm used to working in a therapeutic role--I'm used to doing therapy in my role as a MH nurse--I always work to extend people, rather than just maintain them and CBT allows me to do this. "
The CBT model and approach was one of the key factors promoting the CMHNs' use of CBT, as was an understanding management team. Both Ellen and Nina found the response was positive when they approached their respective managers regarding the need for more time to work with a client. "I mean for me I've never had a problem with saying I need more time to work with someone." (Ellen)
Nina takes any issues regarding her clinical caseload or number to clinical supervision or her clinical co-ordinator. "They're usually pretty supportive. It's just reminding them sometimes--they kind of forget that I'm actively doing CBT with my clients and that I'm not just maintaining them."
Theme 3: Negative influences: The most common factors that negatively influenced the nurses' use of CBT were time and caseload. Each CBT session is individualised and even if a nurse worked with three clients with the same psychiatric diagnosis or clinical symptoms, the format and process of each CBT session would differ greatly. Nina explained: "Even if you've got five doing CBT and if they're all coming once a week, it's still quite a lot to do--and they're all different. So I mean, all the preparation is often different."
Eva shares her thoughts on these issues: "The hindrance really is just the fact that we have this other work we have to do ... we all have to carry a large CMH caseload ... so the hindrance is making the space to do the work, on top of everything else that we're expected to do. I would do more CBT. I mean I'd be happy to just do that full-time but we've got to share the caseload between us."
Other factors that negatively influenced the nurses' use of CBT included the physical environment, medication and acuity and chronicity factors. A number mentioned the use of psychotropic medication as a factor that may and often does hinder their use of CBT. "I think probably the medication as well ... if someone's got a lot of medication on board it's very hard for them to suddenly become flexible in their thinking. " (Ellen)
There were mixed feelings from the participants regarding the degree to which clients' acuity or chronicity impacted on their ability to work within a CBT framework. "We're often looking after people who are quite damaged and long-term damaged as well so their ability to come in and quickly adjust to a CBT programme is very tricky um but I think it's do-able, as long as you and them are willing to accept it's going to take a long time." (Ellen)
Theme 4: Influence of peers and the multidisciplinary team: Discussion was initiated by the participants on the impact and influence of their peers and the multi-disciplinary team. This theme explores how the participants communicate their use of CBT to their team members and also how they work to promote CBT use and extend others' understandings of CBT.
Amelia generally found her work colleagues were informed about CBT and were supportive of her using it. "Everyone seems to be very aware of CBT, whereas not so long ago it wasn't heard of much--but everyone seems to know of it now. Generally my work colleagues, across all disciplines, are very supportive with no collegial 'jealousy' regarding me working from a CBT model. Rather the opposite really, in that they value my skills and knowledge in this area."
Ellen, on the other hand, shared how at times she has been reluctant to talk a lot about her use of CBT to colleagues. "One of the things that hinders me talking about it [CBT] is the fact there's only a small group of other clinicians who have done it and so when you start talking about a CBT model or moving away from the bio-medical model sometimes there's some quite strong resistance to that ... and I've heard it being termed as 'precious' ... it's a kind of "who do you think you are--spouting CBT all the time:" Ellen thought this was related to "maintaining clients" rather than "moving them on" and helping them make changes. "It's easier if we think that the people [clients] aren't curable, 'cause then we don't have any ... you know, if recovery isn't possible, then we don't have any responsibility to do anything other than go and see them, give them pills and check out that they're not going to kill themselves or kill anyone else and that they are eating properly ... so if we stick with that nice square role that just makes my job a lot easier ... I come to work, I do that and I go away again and if you start telling them things they could do differently ... then it's kind of like don't ask me to do that and don't even show you can do it because if you show you can do it then someone might be asking me to do that and I'm not going there, thank you. "
Nina reported the psychiatrists on her team generally had an understanding of CBT and would specifically refer clients to them for this. Helena felt her team generally recognised and accepted CBT.
Theme 1: All participants felt their ability to be "therapeutic" as CMHNs was enhanced by their use of CBT. The participants' use of CBT in this study is consistent with the only other New Zealand study examining CBT use after training. (8) The result of the postal survey conducted during that research indicated CBT training had a positive impact on the graduates' (multi-disciplinary) clinical practice and that their CBT skills were used across a wide range of psychological and psychiatric disorders. (8)
All the participants had experience in using CBT with clients who were clinically depressed. Clinical practice guidelines support this and strongly recommend CBT be made available to all people experiencing depression. (5)
Four of the participants shared their experience of using CBT with clients experiencing voices and/or diagnosed with schizophrenia. The participants' use of CBT with this client group is supported by the Royal Australian and New Zealand College of Psychiatrists. In its clinical guidelines for the treatment of schizophrenia, one of its key messages is that comprehensive psychosocial interventions are an essential part of modern treatment. (11)
Theme 2: The study participants identified that their relationship with a client, when engaging in CBT, was one of collaboration and empowerment and they all recognised the active part the client played in the CBT process.
The fact CBT was empirically validated, had a large educational component, and the CMHNs were able to identify personally with the model and approach, were three of the key factors that promoted the participants' use of CBT.
Under the mental health recovery paradigm, clients are advocating their involvement as equal collaborative partners. They want a process that validates them as people and one that facilitates their empowerment. (12) In the Mental Health Advocacy Coalition's discussion paper, mental health consumers identify the process of CBT as promoting recovery. (13)
The CMHNs felt their use of CBT was "making a difference" to the lives of their clients. The ability to help clients "move forward", rather than just be "maintained", was a recurring theme.
A number of the participants explained that by using a CBT approach to community mental health care and treatment, long-term health gains could be made.
Theme 3: The participants identified a wide number of factors that hindered their use of CBT in their CMHN roles. The most common factors mentioned were time and caseload. The participants explained that not only did they need 60-minute time slots to complete a formal CBT session, but the allocation of preparation time and the post-session reflection time were also critically important. The participants talked about the difficulty of trying to "fit in" CBT sessions with their other caseload responsibilities.
Research has found significant problems in the dissemination of CBT, with the most commonly reported difficulty being time constraints due to client caseload. (14)
Other factors that hindered CBT use included the physical environment, clients' use of medications and acuity and chronicity factors. The physical environment in which to conduct CBT was identified by two of the participants as a significant barrier. They remarked on the smallness of their office and the issue of sound-proofing, with offices situated on a main corridor or thoroughfare. These participants expressed special concern for their anxious or nervous clients.
There were mixed feelings regarding the degree to which the client's acuity or chronicity impacted on their ability to work within a CBT framework. The issue seemed to be more related to the length of time CBT treatment would take, rather than whether or not it would be effective. It is well recognised that different techniques and strategies, such as behavioural and/or cognitive approaches, will be more appropriate, depending on the client's level of wellness.
Theme 4: Community mental health teams in New Zealand are made up of a number of mental health clinicians although, arguably, the majority of them would be registered nurses. The CBT-trained nurses in this study generally found their colleagues supported their use of CBT as a treatment modality. Although most of the participants felt their CBT use was supported by their colleagues, one participant reported that at times she was hesitant to talk about her use of CBT. She had experienced some strong resistance from a very small number of her colleagues and felt this was related to conflict around the bio-medical model of care which "maintains" clients, vs the CBT model which "moves" clients forward.
These CMHNs are effectively using their CBT skills and knowledge on a daily basis and are using their skills with a wide range of psychiatric and psychological disorders. These nurses believe their ability to be therapeutic has been enhanced by their CBT training and that there are factors within New Zealand's mental health services that both promote and hinder their use of CBT.
(1) Stuart, G., & Laraia, M. (2001) Principles and practice of psychiatric nursing. St. Louis: Mosby.
(2) Crowe, M. (1997) An analysis of the sociopolitical context of mental health nursing practice. Australian and New Zealand Journal of Mental Health Nursing; 6, 59-65.
(3) Clinical Training Agency. (2005) Analysis of Mental Health PECT Data. Wellington: The author.
(4) Mueser, K., Corrigan, P., Hilton, D., Tanzman, B., Schaub, A., Gingedch, S. et al. (2002) Illness management and recovery; A review of the research. Psychiatric Services; 53, 1272-1284.
(5) Vos, T., Carry, J., Haby, M., Carter, R. & Andrews, G. (2005) Cost effectiveness of cognitive behavioural therapy and drug interventions for major depression. Australian and New Zealand Journal of Psychiatry; 39, 683-692.
(6) Vos, T., Haby, M., Magnus, A., Mihalopoulos, C., Andrews, G. & Carter, R. (2005a) Assessing cost-effectiveness in mental health: Helping policy-makers prioritize and plan health services. Australian and New Zealand Journal of Psychiatry; 39, 701-712.
(7) Chan, S. & Leung, J. (2002) Cognitive behavioural therapy for clients with schizophrenia: Implications for mental health nursing practice. Journal of Clinical Nursing; 11, 214-224.
(8) Barnfield, T., Matheson, F. & Beaumont, G. (2006) Competency in cognitive behaviour therapy gained, then what? The impact of training on graduates" clinical practice in New Zealand Mental Health Services. Unpublished manuscript.
(9) Tarrier, N., Barrowdough, C., Haddock, G. & McGovern, J. (1999) The dissemination of innovative cognitive-behavioural psychosocial treatment for schizophrenia. Journal of Mental Health; 8, 569-583.
(10) Polit, O., Beck, C. & Hungler, B. (2001) Essentials of nursing research: Methods, appraisal and utilization (5th ed.). Philadelphia, USA: Lippincott Wilkins & Wilkins.
(11) Royal Australian and New Zealand College of Psychiatrists. (2005) Clinical guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry; 39, 1-30.
(12) Elder, R., Evans, K. & Nizette, D. (2005) Psychiatric and Mental Health Nursing. Sydney, Australia: Elsevier.
(13) Mental Health Advocacy Coalition. (2006) Achieving the required paradigm shift in mental health services. Discussion paper (draft).
(14) Kavanagh, D., Clark, D., Manicavasagar, V., Piatkowska, O., O'Halloran, P., Rosen, A. et al. (1993) Application of cognitive-behavioural family intervention for schizophrenia in multi-disciplinary teams: What can the matter be? Australian Psychologist; 28, 181-188.
Jenny Nichols, RN, PGCert.CBT, MN, a nurse with the Child, Adolescent and Family Service, Hawke's Bay District Health Board.
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Sep 1, 2009|
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