Principles and Practice of Mental Health Nursing

Principles and Practice of Mental Health Nursing

 

            One of the strategies employed in addressing a number of psychological problems and illnesses is the use of different kinds of psychotherapy. Aside from pharmacology, many psychiatrists and psychologists practice different techniques in psychotherapy in order to lessen drug-dependence of clients suffering from mental disorders. One of the psychological therapies used is Cognitive Behavioral Therapy, which is a form of psychotherapy that addresses the change in the behavior and attitudes of an individual through mind conditioning. Based on the positive results following its use in the clinical and psychological field, this essay aims to discuss the development of Cognitive Behavior Therapy, and its role in the practice of Mental Health Nursing.

 

Historical and Developmental Background of CBT

            It has been reported that the empirical foundations of cognitive-behavioral approaches to psychological problems can be traced back to the early part of this century (1998). Such cognitive behavioral approaches emphasized a specific learning that responses can be elicited through conditioning, involving positive and negative reinforcements. Since Beck first introduced cognitive behavior therapy for depression, there have been numerous studies demonstrating its efficacy. Beck’s CBT is based on the underlying theoretical rationale that an individual’s emotions, motivations, and behavior are largely determined by the way in which he or she constructs the world. According to Beck and his colleagues, some individuals develop maladaptive schemas that serve as vulnerability factors predisposing them to depression and other psychological disorders (2003). Due to the application of CBT in many fields, this therapy is extended likewise in the field of nursing.

Before the 1950s, the medical model dominated psychiatric-mental health nursing practice. Physicians and psychiatrists assessed, diagnosed, and planned care for individuals with psychiatric disorders. Nurse practitioners were taught and supervised mainly by physicians and psychiatrists who incorporated the theories of individuals such as  into their practice. However, during this same period, nursing leaders began to emerge to provide impetus for the development of psychiatric nursing as an independent discipline. Since the 1970s, nursing theories based on caring, cultural care diversity and universality, modeling and role modeling, energy fields, and human becoming have emerged (2005). Along with such theories is the incorporation of Cognitive Behavior Therapy in the Mental Health Nursing practice. Incorporation of Cognitive Behavior Therapy in the nursing practice, particularly in mental health nursing was founded, based on Orem’s Behavioral Nursing Theory. His theory focuses on self-care deficit, and proposes that the recipients of nursing care are persons who are incapable of continuous self-care or independent care because of health-related or health-derived limitations. In relation to this theory is the perception of human beings, as being described as integrated wholes functioning biologically, symbolically, and socially. Because of an individual’s self-care deficits, a nurse, family member, or friend may educate or consult with the individual to improve the deficit. This theory is used in the psychiatric setting, where individuals may neglect self-care needs, such as eating, drinking, rest, personal hygiene, and safety because of their underlying psychological disorder (2005). In this regard, it can be perceived that the application of CBT in the field of nursing has been based on the studies of Beck and the theory of Orem, which provided the members in the medical and healthcare field adequate proof of the positive effects of cognitive behavior therapy.

 

Treatment of Depression Prior to CBT

            Depression is not simple sadness or bereavement. It goes far beyond merely a sad or depressed mood, and differs from sadness or unhappiness in a variety of ways. The Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV defined depression as a recurring psychological disorder that involve disturbances in emotional, cognitive, behavioral, and somatic regulation, being not a normal reaction to life’s difficulties. A sad or depressed mood is only one of the many signs and symptoms of a clinical depression. In fact, the mood disturbance may include apathy, anxiety, or irritability in addition to or instead of sadness, along with the lack of interest or capacity for pleasure and enjoyment may be evident (1997). Treatment of depression, prior to CBT is through administering classical antidepressants, namely, MAOIs, TCAs, and SSRIs. Classically, pharmacological treatment of depression has consisted of agents that affect neurotransmission involving three monoamines, namely, serotonin, norepinephrine, and /or dopamine. From the 1950s through the 1980s, two classes of agents, the monoamine oxidase inhibitors or the MAOIs and the tricyclic antidepressants or TCAs, dominated the treatment of depression. However, while these two classes of agents are clearly effective in reducing depressive symptoms, including in those patients experiencing severe depression, their side-effect profiles include serious and potentially lethal effects on the cardiovascular system, as well as less dangerous but still troublesome side effects such as sedation, dry mouth, and weight gain. In the 1980s, a new class of agents called the serotonin selective reuptake inhibitors or SSRIs, was introduced. These agents appear to be as efficacious as the older drugs in controlled studies, and offer advantages in terms of simplicity of dosing and side effect profiles. However, the most prominent adverse effects of SSRIs include agitation, akathisia, panic attacks, insomnia, sexual dysfunction, gastrointestinal effects and headaches. These side effects, while generally not as troublesome as the cardiac toxicity and anticholinergic effects of the older agents, are nonetheless disagreeable and may lead to non-compliance (2003). In this regard, it can be understood that prior to the use of CBT in treating depression and other depressive disorders, pharmacology is the most used treatment.

 

Rationale of Principles and Practice of CBT

            It has been reported that the use of CBT involves two central tenets, where one emphasizes that one’s cognitions have a controlling influence on his or her emotions and behavior, and the other is that one’s actions or behavior can strongly affect his or her thought patterns and emotions (2006). Because one’s behavior and emotions holds a strong control on the pattern of his or her thoughts and actions, it can be perceived that a therapeutic relationship between a nursing practitioner and a mental patient can be difficult to achieve, most especially in terms of addressing problems in relation to depression. It has been emphasized that in the context of a therapeutic relationship, the relationship that must be formed between the nurse and the client must be characterized by warmth, accurate empathy, and genuineness. Building trust and rapport are crucial ingredients when treating depressed clients with CBT. It is also important to elicit client feedback regularly in order to check and the client’s understanding of the therapy and to assess for any adverse reactions that may impede the therapy process (2003). However, certain protocols and strategies must be done in line with the use of CBT as treatment of a depressed client. It has been mentioned that depression is characterized by certain behaviors, such as irritability, which may lead to aggression when provoked, or the lack of interest or capacity for pleasure and enjoyment, which can lead to apathy. Given these two situations, the application of CBT can be tested.

            A depressed client can be observed to exhibit irritability that may lead to aggression, when provoked by a certain situation. Such behavior is provoked through the memories of the client, which is being refreshed by certain objects or situations. Rather than create new memories, cognitive therapy for depression attempts to limit the ease with which these memories are activated by the current environment. One feature of depression is that negative mood changes are elicited by a wide range of stimuli. Clients respond to many relatively harmless situations as though these situations contained enormous potential for various psychological and physical threats. The nursing practitioner can infer the content of these representations by systematically gathering data about the situations that elicit depression or irritability in a person and about the person’s reactions to such situations. By drawing attention to the client’s apparent assumptions and challenging these with the use of logic and behavioral experimentation, the nursing practitioner can help the client develop new rules for discriminating situations that are truly threatening from those that merely arouse the feeling of being threatened ( 1996). In relation to apathy and the lack of interest for pleasure and enjoyment, the interacting cognitive subsystems theory can be used, which suggests that the function of therapy is to disrupt the repeated synthesis of high-level schematic models containing generic meanings prototypical of previous depressing situations or the so-called depressive interlock. Disruption of interlock may be achieved in a number of ways. For example, if the models were continually being activated by ongoing stress, problem-solving training aimed at resolving the stress might effectively deactivate them. Physical exercise might alter a person’s body state and create a new element capable of disrupting the particular pattern of interlock ( 1996). As such, the negative actions associated with depression, such as irritability and apathy can be replaced by positive behaviors through the different examples and strategies mentioned.

Limitations of CBT

            Despite the success of CBT in treating depression, both in the psychological and nursing fields, a number of limitations can be recognized in relation to a wider mental healthcare provision. It has been mentioned that in order to make CBT work, an effective and efficient therapeutic relationship must exist between the nursing practitioner and the client. However, a therapeutic relationship may not be as successful, based on a number of reasons. Primarily, the therapeutic relationship would not be effective in achieving healthy outcomes without the trust of the client to the nursing practitioner. If the client has schematic beliefs of mistrusting other people, then the nurse would have a hard time encouraging the client to disclose information. In this regard, the genuineness of the nurse must be observed, which has to do with confidence, appearing relaxed and at with one’s self, thus, presenting the therapy in a way that it would not sound artificial to put up a barrier between the therapist and the client ( 1995). Another hindrance to the practice is the lack of sensitivity on the part of the nurse. If the nurse is not sensitive enough for the needs of the client, then the client would not be able to obtain the best treatment that would help him or her to improve and develop as an individual. It is not enough that probing and collaboration with the client must be done, but the client must be able to feel the care and concern of the nursing practitioner. Therapeutic relationship is also not enough if there is incompatibility between the client and the nurse. Incompatibility can be observed through the incompatibility of the approaches of the nursing practitioner, and incompatibility on the response of the client that hinders adequate and effective assessment. In addition, the time allotted by the nurse also counts in cognitive behavior therapy. However, psychotherapies, such as cognitive behavior therapy takes a lot of time and effort on both the client and the nurse, are a time-consuming process, and its full analysis may take several years (1988). The problem that can be encountered due to the slow and time-consuming process is that the client or the nurse may get tired, given the slow development of the client. In this case, psychotherapeutic activities must be done simultaneously to ensure the speedy improvement and treatment of the client.

 

Relevance of CBT in Mental Health Nursing and Nursing Practitioner

            The nursing practitioner would be able to learn new skills and information regarding the nursing practice, thus, making nurses more involved and knowledgeable in their field. Because CBT is used in treating psychological disorders, nursing practitioners can help alleviate the psychological sufferings of clients and their families, as treatment for psychological disorders is a tedious process. Through knowledge of CBT, nursing practitioners would be able to provide assurance to the clients and to the client’s family that help is on their way and they are not being abandoned by medical and healthcare institutions. In addition, in the future, the work of nurses would not only be focused in providing medical and healthcare to known medical conditions, but also in providing talk therapies and therapeutic communication to clients with psychological disorders.

 

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