In this essay, I will be look briefly at the therapeutic structure from nursing perspective and explore the use of cognitive behaviour therapy (CBT) in the acute in-patient psychiatric ward (AIPPW) at the South Kensington and Chelsea Mental health unit SK&C MHU .
The clients group at the SK&C MHU is predominately people with complex psychiatric needs (CNWL NHS Foundation Trust) characterised by schizophrenics, depression personality disorder OCD and a raft of other diagnosis and co existing diagnosis. The acute psychiatric inpatient wards are predominately staffed by registered psychiatric nurses (RMN) and health care assistance (HCA). The combination of these two category of nurses staff the ward on a 24 hour bases. On the global multidisciplinary team are 5 consultant psychiatrist, 2 occupational health professional and one occupational health assistance and a half of a psychologist.
CBT Cognitive-behavioural therapy (CBT) is a short- term, problem-focused psychosocial intervention. Evidence from randomised controlled trials and meta- analyses shows that it is an effective intervention for depression, panic disorder, generalised anxiety and obsessive-compulsive disorder (Department of Health, 2001).
Increasing evidence indicates its usefulness in a growing range of other psychiatric disorders such as anxiety, hypochondriasis, social phobia, schizophrenia and bipolar disorders and others. CBT is also of proven benefit to patients who attend psychiatric clinics (Paykel et al, 1999). The model is fully compatible with the use of medication. Studies examining depression have tended to confirm that CBT used together with antidepressant medication is more effective than either treatment alone (Blackburn et al, 1981). CBT treatment may lead to a reduction in future relapse (Evans et (as cited Chris Williams and Anne Garland)(Advances in Psychiatric Treatment (2009) 15: 306-317. doi: 10.1192/apt.bp.107.003731)
current nursing tools in SK&C
The nursing tools used at the SK&C MHU for assessment and structure of treatment is the nursing models. (Rambo, 1984) defines nursing model as a collection of interrelated concepts that provides direction for nursing practice. In nursing practice, nursing models approach the nursing process in a logical, systematic way; the model influences the very data the nurse collects. Nursing models have become far more prevalent since the 1970s. Prior to this, nursing care was largely dependent on the medical model (Rambo, 1984) and nurses practised largely by intuition and experience (Leddy & Pepper, 1993). Tiedeman, Mary E. PhD, RN; Lookinland, Sandra PhD, RN, looked in to the models of nursing and concluded that there is little or no evidence to determining which model of care is most effective in any given situation considering quality of care, cost, and satisfaction for the models of care, despite lack of evidence, newer models continue to be implemented. June 2004 – Volume 34 – Issue 6 Traditional Models of Care Delivery: What Have We Learned?
The case for CBT in AIPPW
mental health policy implementation guide: acute inpatient care provision (2002b) points out the fact that clinical psychology input needs to be increased and training to assist ward staff in acquiring skills. The desire for psychological improvement in AIPPW in long standing the and long over due Manpower Advocate Service
Anthony Morrison wrote in his foreword in the book cbt for acute inpateint mental health unit pg xv1 that thought there is limited evidence to suggest the provision of cbt in the inpatients setting, there is sufficient evidence to show that it will speed up recovery in the AIPPW. the current medical/nursing model of care by them self is is flawed. An investigating In CBT in the inpatient psychiatric wards (2005) survey by the Sainsbury centre, reported that less that 20 per cent of the wards surveyed reported patients having assess to CBT. A random survey of 263 APIPW with a total of 5971 beds in England and Wales by the Mental Health Act Commission found that there was a mean on 0.3 staff per patient. On the day on the survay there were no staff, patients interacting BMJ 1998;317:1279-83. B. Lloyd-Evans, PhD and S. Johnson, DM 2010 found on significant change in patient contact even in inpatient setting with significant more psychologist.
Chris Williams & Anne Garland stated in their article (A cognitive-behavioural therapy assessment model for use in everyday clinical practice) that CBT can be part of an integrated treatment biopsychosocial modelled assessment in a joint up manner of medical, nursing and psychological management approach,
Kim SY out lined these situations in which CBT should be particularly considered
” Where the patient prefers to use psychological interventions, either alone or in addition to medication The target problems for CBT (extreme, un- helpful thinking; reduced activity; avoidant or unhelpful behaviours) are present No improvement or only partial improvement has occurred on medication Side-effects prevent a sufficient dose of medication from being taken over an adequate period, Significant psychosocial problems (e.g. relation- ship problems, difficulties at work or un- helpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone” Kim SY. In the March 2007 Am J Psychiatry article 164:428-436, they found a modest improvements in psychosocial functioning after the introduction of anti psychotic medication in all treatment groups. This improvements is a gate way for the introduction of CBT . (Kuipers et al. 1998; Tarrier et al. 1998a) demonstrated in a controlled studies that CBT can significantly benefit chronic psychotic patients. CBT is not globally available in SK&C MHU.
(National institute of clinical excellence (NICE)
CBT: to meet the criteria for CBT, interventions had to have a component which involved recipients establishing links between their thoughts, feelings or actions with respect to the target symptoms; and the correction of their miss perceptions, irrational beliefs or reasoning biases related to those symptoms. At least one of the following was also required: self-monitoring of the treated person’s thoughts, feelings or behaviours with respect to the target symptoms; and the promotion of alternative ways of coping with the target symptoms. Anthony Morrison1 describes resistance from the medical team for this approach.
The CBT Assessment and formulation in the AIPPW
CBT assessment aimed at collation of clients past, present and current information via afferent modes(Hawton, Salkovskis, Kirk and Clark 2010) of assessment direct observation in clinical setting, physiological measures, behavioural interview, self-monitoring self-reporting , information from others . In the inpatient wards, the initial assessment, is characterised by clients feeling consumed by the severity of their symptoms, fear and uncertainty Gillian Haddock & Peter D Slade 2000, pg75
“It is common for people admitted to psychiatric care to lack the mental capacity to make
decisions on treatment, particularly if they have mania, schizophrenia or have been detained using the Mental Health” This put the nurse in a position to do a thorough assessment from the initial welcoming of the client where the nurses observational skills will aid the assessing and recording of clients responses mainly emotions, behaviour, cognitive and physiological. While the patient is in an acutely phase of ill, this has become possible comparing to the “cognitive revolution” proposed by Mahoney (1974,1984) as sighted Sharon Morgillo freeman and arthur Freeman 2005, to the advent of third wave paradigm of CBT where a the path way to change lies in altering feelings and not thought (Segal et al 2000) by assisting patents in managing distressing feelings though mindfulness (Chadweick et al 2005)
Sharon Morgillo freeman and arthur Freeman 2005, pg 62 suggest the the aim of the initial assessment is in the preparation of therapy, assessment of person and the presenting problem, the conceptualization of problem according to the cognitive model, socializing the person to the cognitive model and identifying goals and appropriate interventions consistent with the model
Nurses are in the best position to begin the construct of clients problem conceptualization as expressed by Judith S. Beck 1995 page 13 ” A cognitive conceptualization provides the framework for the therapist’s in understanding of a patient” “Conceptualizing a patient in cognitive terms is crucial in order to determine the most efficient and effective course of treatment”. Currently there is a disjointed approach in that, the medics have a ward round with or without the nurses thought nurses do give them hand overs, the psychologist have their meetings excluding the medics and the nurses thought points of interest are disclosed. Of the three professional groups, the nurse is in a 24 hour loop placing them in a better position to captures the present and previous medical and psychiatric treatment histories and also invaluable brings the ever changing present history together, will capture the case formulation. Mayer and Turkat (1979:261-262) defines case formulation as ” a hypothesis which (1) relates all the clients complains of one another (2) explains why the individual developed this difficulty and (3) provide predictions concerning the clients behaviour given any stimulus condition. The accuracy of the formulation depends on a sound therapeutic alliance to foster collaboration and active participation in the formulation, it is essential for there to be complete collaboration so the information collated during the acute phase should be treated sensitively as it may be embarrassing and distressing. Anthony (1993) emphasis is to be placed on person rather than illness as the level of insight may vary and their views and belief of their illness or problem may not be congruent with that of the therapist. in a trail in 1999 by G. Haddock á N. Tarrier á A.P. Morrison á R. Hopkins R. Drake á and S. Lewis. Of 21 client that started Cbt for a year, 20 completed treatment
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Butler (2006) point out and reasoned that two different CBT given the same client could develop different case formulations. This will not be the case with nursing team case formulation. Once insight is regained, the nurse team are in a better position to measure and assist with the different techniques of assessment like the use of daily mood logs, activity scheduling, behavioural surveys etc. The CBT approach is the use of recognised approaches and techniques of CBT to treat or deal particular issues. These employ the use of keeping of diary of events and feelings and the possible links, behaviours and thoughts, questioning and testing cognitions and assumptions, evaluating unhelpful and unrealistic beliefs, gradual exposure to activities that may have been avoided, trying out other ways of reacting and behaving and the use of medications to adjunct CBT to treat conditions like bipolar disorder. The sessions are structued useing J Beck’s 5 essentially elements of CBT session namely 1, agenda setting 2, identification of and dealing with problems, 3, periodic feedback 4, homework 5 summary (J. Beck 1995) there will be consistency of treatment from the team..
Factor that may hinder Commitment to CBT
length of stay in hospital, patients being detained rather than being willing participants of a process. Cost of hospitalization crisis teams to facilitate early discharge from hospital and treatment many patient admission are involuntary hence their willingness to engaged may be affected lack of insight engagement may be a problem looking forward to early discharged with the crises team early discharge in that with the advent of criss resolution teams (CRT), unwillingness to discuss painful issues
Case Against CBT on the ward,
The Guardian, Thursday 18 October 2007, Andrew Samuels ” if anyone seriously believes that all levels of mental-health issues can be fixed by CBT alone they are seriously mistaken”
Marion Rickett a psychotherapis expresses There is a case to be made that NHS emphasis on CBT distorts the evidence about the complex factors that are important in psychological therapies
A dark age for mental health, October 13 It is welcome news that funding for talking therapy is to be increased cited in the 18 October issue the idea that there is open discussion in a respected news paper opens the further research and hence attract funding.
Andrew Samuels Everyone has been seduced by CBT’s apparent cheapness.”He considers CBT, “a second-class therapy for citizens deemed to be second class.”
The average stay on an acute psychiatric ward is 28 days but corresponding average length of a Cbt treatment is 12 weeks is
In a meta-analytical review of well-controlled trials in a 2009, the question of CBT for major psychiatric disorder: does it really work was asked the authors argued that no trials using blinding and psychological placebo has found data suggest CBT to be effective in schizophrenia. The was a further findings that concluded that fewer well-controlled studies of CBT in depression found the therapy to be effective, and that CBT is not effective in the prevention of relapses in bipolar disorder.
Dr Andrew Keen concluded that Reliable assessment of standard competencies in CBT is a complex and resource intensive. There would need to be a marked increase in the number of samples of clinical work assessed to be able to make reliable judgements about proficiency” The British Journal of Psychiatry (2008) 193: 60-64. doi: 10.1192/bjp.bp.107.038588 this will not be an issue as CBT Skills, cases and supervision will be used on a 24/7 basis cases in the clinical.
CBT is a viable clinical tool that will be effective in the AIPPW NICE has guidelines covering almost all illness areas covered on the AIPPW CBT is seen as a short-term effective therapy. The nurse is in the clinic area 24 hours 7 days a week, training and incorporating the nursing team will a, reduce the waiting list problem in client having to wait for treatment b, improve clients satisfaction for treatment c, cost effectiveness of treatment.(Centre for Economic Performance 2006)
Clack and Wilson (2009) pg 23 point out that the usefulness of psychological approach is highlighted in several Department of Health documents(DH 1996, 200 1b, 2004a, 2004b, 2006a) and that Service users are increasingly demanding psychological services. They also point out that other department namely Department of Work and Pensions have seen the cost effectiveness CBT
as is reflects in randomized controlled trials. ( Layard 2004, 2006).
guided discovery Socratic questioning
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