Mental health nursing is a complex healthcare practice, because it aims to meet the needs of clients with mental health needs, which are usually also complex and require more than a single therapeutic approach. Mental health nurses usually provide supportive and therapeutic care adhering to nursing and healthcare principles of beneficence and non-maleficence, and adhere to the principles published in the national guidance, of client-centred care focused on service user need, as enshrined in the National Service Framework for Mental Health (Department of Health, 1999). Mental health nursing usually involves the provision of ongoing, supportive therapeutic interventions and ‘talking’ therapies, which can include counselling based on established principles. This role of the mental health nurse involves the formation of a therapeutic relationship with the client, in order to support the client to development self-management and coping strategies for the ongoing control of their condition and its symptoms, in conjunction with pharmacological treatments.
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This critical essay will explore the mental health nursing care of a particular, identified patient encountered in clinical practice, in whose care the author was directly involved. It explores the provision of Cognitive Behavioural Therapy (CBT) to a single client who had complex health needs and challenging symptoms, reviewing the usefulness and appropriateness of the therapy, the effects or projected effects on the client’s wellbeing and symptoms, and the issues surrounding such care for the client in relation to rehabilitation and recovery as part of their mental health journey.
The essay will focus on the care of one client with depression and suicidal ideation, looking not at the acute phase of mental health care, but the rehabilitation phase where the client is being supported into ways of managing symptoms and returning to a useful, active social life where they can function effectively within society. The essay focuses on the goals and principles enshrined in the NSF for Mental Health (DoH, 1999), that of achieving the best possible standards of health and wellbeing for the client and the best possible control of their symptoms. It will explore the rationales and process of the therapeutic intervention, and use this intervention within a person-centred model of counselling, support and care.
Client Background and History
The client, who for the purposes of this essay will be called Lisa (this being a pseudonym used to ensure client confidentiality), is a 19 year old young woman with a history of depression and suicidal ideation. Lisa first presented to the local mental health services at the age of 16, after an acute episode of physical self harm and attempted suicide. Lisa’s self-harming behaviour takes the form of cutting, usually to the arms, legs and abdomen, although she has been known at times to also cut her face and neck. During her first admission, Lisa was diagnosed as having Depression with Psychotic symptoms. She has been managed with a combination of Fluoexetine and a range of other medications, but is known to have frequent relapse due to medication non-compliance.
Lisa has a complex personal and social history which goes some way to explaining her current state of mental ill health. She was abandoned by her single parent mother at the age of 11, from which time until the age of 16 she spent in local authority care, a mixture of foster homes and care facilities. At age 16 she left care and went on the streets, but at 17 after her third hospital admission was able to get into a social support programme, secure accommodation for herself, and start to attend college. Lisa is still at college, studying beauty therapy. She has a history of sexual abuse, but for the past year and a half has been living a relatively stable life, with a good social life and a busy college life.
Lisa has presented this time with a relapse in her Depression, and has demonstrated a strong suicidal ideation, low mood and being very withdrawn and apathetic. She has, this time, attempted suicide through overdose of a friend’s prescribed medication accompanied by severe cutting to the arms, legs and breasts. After being medically stabilised, she was admitted to the mental health ward, and after two weeks on the ward, fully compliant with her medication, was making some progress towards rehabilitation.
Norman and Ryrie (2004) describe mental health nursing as a process of working with clients to allow them to develop the skills to regain control over their lives through managing their mental health. Ultimately, mental health nursing supports clients into a phase of recovery (Tschudin, 1995), which means that they are not overwhelmed by their symptoms and can manage them through a combination of medication, personal supportive therapies, and other support, in order to lead ‘normal’ lives within society and achieve personal goals. Mental health nursing is based upon a range of principles, some of which are scientific, some of which are more holistic (Norman and Ryrie, 2004). Mental health nursing supports clients through the acute phases of their illness, via crisis management, and through the chronic stages of their illness, through longer-term processes of rehabilitation (Perkins and Repper, 2004). Quite often, mental health service users are viewed in terms of their disease and its treatment, but the provision of true client-centred care should start off with a good understanding of the client and their condition, their particular needs, and then be followed by a judgement about how best to help them towards recovery along the spectrum of mental health and illness (Perkins and Repper, 2004; Foreyt and Poston, 1999). Recovery cannot be considered as a finite point in time, but as an ongoing balance between the client and their illness, wherein the client aims to achieve the ability to function at the level they desire, through accessing appropriate support (Perkins and Repper, 2004; Greenberger and Padesky, 1995)). The judgement about what kind of support is best is based upon a number of factors, but most often, the decision about which of the many approaches to supportive therapies and counselling will be used is based upon both the client need, and the mental health nurse’s own knowledge about, experience of, and preference for, a particular form of therapy (Puentes, 2004).
Mental health nurses, therefore, must have a good understanding of themselves, their philosophical orientation in relation to counselling, and the therapies on offer, and are most likely to provide those with which they have the most familiarity. In this case, the author is describing their own philosophical approach as matching that of their clinical practice mentor, who, as an experienced mental health nurse, is a strong advocate of client centred approaches to counselling. Gamble and Curthouys (2004) describe these approaches as being founded on Rogerian principles that include empathy, genuineness and unconditional positive regard. Rogers (1957 in Gamble and Curthouys, 2004) suggest that within a therapeutic relationship, which is a supportive relationship between client and nurse, with the express goal of attaining rehabilitation or recovery, there should be certain features which support the client towards ‘functionality’. Thus, there needs to be contact between two people, nurse and client, in which the client is in a condition of incongruence, and the nurse a state of congruence, and in which the nurse displays unconditional positive regard, and empathetic understanding, towards the client (Rogers, 1957 in Gamble and Curthouys, 2004). The nurse must be able to communicate these factors to the client, within the client’s frame of reference (Rogers, 1957 in Gamble and Curthouys, 2004
Bryant-Jefferies (2006) argues that the therapeutic relationship must be founded on empathy, and that in order to achieve empathy the nurse must employ active listening, and must attend to all the signs and the kinds of communication which the client displays, providing a sense of being ‘present’ with the client in whatever experience they are retelling or currently experiencing. One of the more challenging aspects of developing such a relationship with the client is the provision of unconditional positive regard, which Bozarth and Wilkins (2001 in Bryant-Jefferies, 2006) describe as an ongoing, unceasing and unflagging ‘warm acceptance’ of the individual, regardless of what they might say. Some authors describe this as the element of the therapeutic relationship that is most likely to support the client towards recovery (Bozarth and Wilkins, 2001 in Bryant-Jefferies, 2006). In this case, the mental health nurse (the author’s mentor) who was the primary support person for the client, fully aspired to such principles and to the concept of developing the best possible therapeutic relationship with the client. The literature consistently demonstrates that the quality of the therapeutic relationship is fundamental to the client achieving a state of mental health and wellbeing (DoH, 2001; DoH, 2006; Nice, 2004). The author agreed with this and felt that their own therapeutic philosophy was founded upon similar principles, making it appropriate to get involved in the case. The client was also happy to have the author present, as they were involved in there are from admission, and had spent some time observing the client during the acute phase to prevent further self harm.
Depression is a surprisingly common, yet often serious mental illness, which can present in a variety of ways, with features such as “low mood, lack of enjoyment and interest, reduced energy, sleep disturbance,appetite disturbance, reduced confidence and self-esteem, and pessimistic thinking” (Embling, 2002; p 33). According to Embling (2002), these symptoms can have a significant effect on people’s ability to take part in normal daily life or social activities, and in particular, the low mood and predisposition towards pessimistic thoughts can have a negative impact on thought processes, leading to suicidal ideation (Rollman et al, 2003)..
There are a number of individual and social issues which have been shown to have an association with depression, including physical illness (acute and chronic), poverty or low socioeconomic status and deprivation, divorce, bereavement or relationship breakdown, loss of a job or sudden, negative change in circumstances, ethnic minority status, and concomitant mental illness (Embling, 2002). It is a chronic condition which can manifest in acute episodes which are often successfully managed with pharmacological and non-pharmacological support, but the relapse rate is high for many patients (Embling, 2002). It can range from mild depression to severe depression or anywhere along a spectrum in between (Rollman et al, 2003). A wide variety of therapeutic approaches have been used in treating this illness, and in Lisa’s case, she had had some success previously with solution-focused brief therapy, but had found herself relapsing once regular, close contact with a mental health nurse had lapsed. Lisa admitted that she felt the time was right to take control of her life and find ways of coping with her illness more independently, and was keen for strategies which would allow her to avoid having such serious relapses, because they themselves had a negative effect on her life and potential career. Therefore, it was agreed that CBT might be the optimal approach. Luty et al (2007) argue that CBT is not always the most efficacious therapeutic choice for severe depression, but in Lisa’s case, it seemed worth trying, particularly as her worst symptoms were related to not maintaining her medication, and once she was on her medication, the focus had to be on keeping her well enough to keep taking the tablets. Other literature suggests that CBT is effective in patients who have had a history of sexual abuse (Price et al, 2001) This seemed to imply that the focused approach to support that CBT offered would the right way, particularly as it is so focused on relapse prevention.
According to NACBT (2007) cognitive behavioural therapy is the term used to describe a variety of therapeutic or interpersonal interventions, all of which are characterised by a focus on the importance of how clients think, and how this thinking impacts upon their feelings, their responses to stimuli and stressors, and their actions. Its value lies in the fact that it is structured, directive, and also time-limited, strong focusing client and nurse on the current problem, on how the client feels and thinks at the single point in time that therapy is taking place (Embling, 2002). CBT is based on “the theory that the way an individual behaves is determined by his or her idiosyncratic view of a particular situation, thus the way we think determines the way we feel and behave ‘”(Embling, 2002p 34).
According to Embling (2002), Beck et al (1979) introduced CBT , suggesting that “CBT can treat depression as it helps the client to evaluate and modify distorted thought processes and dysfunctional behaviours” (Embling, 2002) p 38). According to NACBT (2007) CBT has expanded within the therapeutic domain to include a range of approaches based upon the sample principles, including, Rational Behaviour Therapy, Rational Emotive Behaviour Therapy , Rational Living Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy, all of which are based on what are described as “cognitive models of social response”. These in turn have been based on philosophical principles derived from Socratic thought, wherein individuals aim to attain a state of calm and tranquillity when challenged by stressful or difficult situations and experiences (NACBT, 2007). Thus the idea is to modulate the responses to life and experiences which precipitate symptoms of mental illness. The counsellor directs the client to use inductive methods combined with principles of rational thinking and educative approaches, to support behavioural self-managed over the longer term , (NACBT, 2007; Sensky et al, 2000) and to prevent relapses (Bruce et al, 1999). Therefore, in CBT, the nurse provides the client with the ability to explore their behaviours, their responses and their typical symptomatic responses in particular in certain situations, and assists them in developing ways of mediating such responses so that they do not relapse into behaviours characteristic of their illness (Sensky et al, 2000; RCP, 2007; BABCP, 2007).
Management of Lisa’s Care
To begin with, it was really important to ensure that Lisa’s counselling and therapy was truly person-centred, in order to develop a good relationship between Lisa, the primary nurse and the author (NELMH, 2007; Moyle, 2003). The author hoped that Lisa would respond well to this approach because it would allow for the demonstration of empathy and a good understanding of how her life, previous mental illness and personal circumstances were contributing to her current illness, and therefore would support congruence in provision of support to meet her needs and address her specific concerns. However, the difficulty in achieving congruence here was that the author could not really claim to fully understand the effects of Lisa’s previous experience of sexual abuse or really relate to her experiences, and in particular, the author found some elements of her history, including the stories she told relating the sexual abuse, as very disturbing. The author discussed this with the nurse mentor prior to the counselling sessions, and discussed how to achieve that true sense of congruence and presence, without communication their own abhorrence of the experiences that Lisa was relating. It was decided that it would be acceptable to tell Lisa that the author was appalled by these experiences, because this would underline the fact that she should not have had to suffer this abuse and that she was right to seek help in dealing with the effects on her mental health. Therefore, the author was able to enter into this counselling in supportive frame of mind, and able to achieve empathy without communicating negative feelings to the client.
The focus of Lisa’s CBT was on the suicidal ideation/self-harming and the low mood and self-abhorrence that were the main manifestations of her depression. Collins and Cutcliffe (2003) show that one of the most common features displayed by mental health service users with suicidal ideation is hopelessness. This was certainly the case for Lisa, who displayed a sever pessimism about life and her ability to achieve anything like lasting recovery. Her goals to become a beauty therapist seemed unobtainable, and she felt she had no hope of making a new life for herself that was not ‘ruined’ by her previous life.
However, Collins and Cutcliffe (2003) recommend CBT for this kind of pessimistic thinking because it focuses the client on establishing ‘hopefulness’ within their thought patterns. Other research shows that suicide risk can be reduced if individuals can experience others showing concern for them (Casey et al, 2006). This was supported by the author’s and the mentor’s firm belief in the efficacy of CBT for clients such as Lisa (Joyce et al, 2007). Thus, it was possible to establish an initial level of trust, and through the therapeutic relationship, the author was able to support Lisa in exploring her conditional assumptions (Curran et al, 2006) which led to the ongoing, spiralling pessimism, and then using CBT, we were able to set goals for each counselling session, set ‘homework’ which focused on self-management, and then reflect on progress as each session followed the previous one (Curran et al, 2006). The sessions focused on relapse prevention through changing cognitive patterns and schema, rehearsing relapse drills, and ensuring ongoing compliance with medication (Papakostas et al, 2003. While some authors argue for the need for inclusion of family or carers in therapeutic interventions such as (Chiocca, 2007), this was not possible with Lisa because she had no family and although she had a number of good friends made through her college course, none of them knew of her mental illness. The focus was therefore on health education, developing personal skills, and helping Lisa to cope with issues such as her current socioeconomic status (Jackson et al, 2006; Cutler et al, 2004).
If, as Calloway (2007 p 106) suggests “nursing is defined as a profession that protects, promotes, and restores health and that which prevents illness and injury”, then using such a client-empowering form of therapy, one which is based on the development of realistic coping mechanisms (Salkovskis, 1995; Deakin, 1993), was the right approach with Lisa. Discussion with her revealed that focusing on relapse prevention, within an honest therapeutic relationship which addressed the factors affecting her mental health, and addressed the ways of thinking and behaviours which led to relapse, was the right approach, because these were, fundamentally, her primary needs. The person-centred approach, in particular, seemed to give her the positive, ongoing interpersonal contact she needed, such that she did demonstrate signs of moving into a state of rehabilitation and recovery.
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