Cognitive Behavioral Therapy and Interpersonal Psychotherapy in Nursing - Essay Example

?Running Head: Nursing Cognitive Behavioral Therapy and Interpersonal Psychotherapy Introduction Theoretical work in nursing is remarkably comprehensive. Even though there is an ongoing debate about whether theories in nursing are thoroughly advanced or developed enough, nursing theories have become the foundation for understanding and practicing nursing in the contemporary period. Even though theories of nursing generally are introduced with the claim that they are focused on identifying and explaining issues of nursing, each is derived from scope, frameworks, ideas, principles, and knowledge that are unique (Wheeler, 2008). Although theories of nursing generally are not introduced with consistency among the theories’ process, structure, and parts, it is not very difficult to identify the principles and ideologies of the theories that reveal how nursing practices and behaviors are addressed theoretically. This essay discusses two leading nursing theories, namely, (1) cognitive behavioral therapy and (2) interpersonal psychotherapy. The first section presents a separate discussion of these two nursing theories. The second section determines the similarities and differences between these two nursing theories in terms of major tenets, concepts, views, techniques, view of pathology/normality, etc. The third section discusses the relevance of these two nursing theories in nursing practice. The fourth section gives recommendations for advanced nursing practice in relation to interpersonal psychotherapy. The last part is the summary and conclusion of the entire paper. Cognitive-Behavioral Therapy Even a quick look at current literature in the discipline of child psychology suggests that the cognitive-behavioral theory has received significant empirical and clinical attention in recent times. Cognitive-behavioral therapy (CBT) has been effectively used in a broad array of medical disorders experienced by children, adolescents, and adults, such as learning difficulties, eating disorders, anxiety, and depression. According to Abela and Hankin (2007), cognitive-behavioral therapy is highly recognized for its focus on factors that make individuals vulnerable to emotional and behavioral difficulties, for its emphasis on the importance and function of the social context/environment and family in the growth and continuation of these problems, for its focus on unspoken ideas about the self and how these could affect emotional and behavioral wellbeing, and for its attention to scientific/empirical assessment approaches to psychopathology and the usefulness of treatments or interventions obtained from them. Cognitive therapy is rooted in the idea that behavior is capable of adjusting and that there is a connection between a person’s behaviors, emotions, and thoughts. A primary focus in cognitive-behavioral therapy, especially with adolescents, is on having an accurate knowledge of an individual’s behavioral pattern and the associated perceptual and cognitive components (Abela & Hankin, 2007). Cognitions are defined as “an organized set of beliefs, attitudes, memories and expectations, along with a set of strategies for using this body of knowledge in an adaptive manner” (Reinecke, Dattilio, & Freeman, 2006, 3). Basically, cognitions denote an individual’s existing ideas or self-awareness, including expectations, values, objectives, attitudes, judgments, memories, and perceptions. It is crucial to take into account each of these factors when trying to understand and treat emotional and behavioral disorders. It is not possible, therefore, to differentiate the cognitive from the social. Cognitive processes are achieved, sustained, and operate in social environments. They are shaped and strengthened by parents, members of the family, and others in the immediate environment of the child, and play an adaptive role in structuring and controlling the child’s reactions to traumatic life episodes (Reinecke et al., 2006). This point of view is in agreement with the clinical finding that it can be somewhat complicated, in practice, to understand and cure clinical difficulties acquired by children and adolescents without dealing with their peer group and home setting. It is seldom predicted that children or adolescents would exhibit significantly alike emotional or behavioral responses if there were major adjustments or changes in their social environment or home setting (Reinecke et al., 2006). One of the basic arguments of cognitive-behavioral therapy is that cognitions affect behavior and emotions. Similar to adults, children and adolescents are thought to act in response to cognitive images of occurrences, instead of the occurrences themselves. This is a crucial hypothesis because it identifies cognitive change as a requirement of emotional and behavioral treatment. Nevertheless, this does not necessarily imply that cognitive components are required or adequate causes of psychopathology (Abela & Hankin, 2007). According to studies, there is no single cause of psychopathology in children. Instead, studies report that adjustment and behavior are diversely developed, and that several factors act together in furthering the growth of emotional and behavioral disorders. Environmental, cognitive, social, and biological factors mutually control one another in making children vulnerable to emotional and behavioral disorders (Abela & Hankin, 2007). Similarly, according to Carr (2008), there seems to be an array of social, cognitive, and interpersonal variables that play a defensive role and reduce such vulnerabilities. Consequently, some children, when experiencing traumatic life episodes, develop mild anxiety, while other children develop quite serious adjustment disorders. The term ‘multifinality’, adopted from the developmental psychopathology field, explains this concept (Reinecke et al., 2006, 4). Basically speaking, it suggests that children born with the same circumstances, or who are subjected to the same experiences, may show strikingly dissimilar outcomes later in life. The objective of CBT is to determine factors that could explain such dissimilar outcomes (Reinecke et al., 2006). The challenge for scholars and clinicians is to try to identify how environmental, biological, and cognitive factors work together over time in moderating the growth of psychopathology in children. It is these behavioral and cognitive variables that become the emphasis of the clinical interventions of cognitive-behavioral therapy (Wheeler, 2008). Taking this into account, cognitive-behavioral therapists work to help children, adolescents, and adults by reinforcing the growth of new behavioral and cognitive abilities, and by exposing children to experiences that will make cognitive change possible. Cognitive-behavioral therapy most usually starts with a thorough evaluation of variables contributing to the children’s emotional and behavioral problems. This normally includes gathering of personal and objective statements from the children, guardians or caregivers, and school authorities. Preferably, these data should be backed up by direct or first-hand behavioral observation (Abela & Hankin, 2007). Evaluations are performed not just of the children’s behavior and disposition, but also of the entire array of environment, social, and cognitive factors that could bring about and sustain these children’s anxiety. This evaluation is followed by the presentation of interventions intended to enhance behavioral skills, as well as methods developed to change maladaptive cognitions or ideas (Abela & Hankin, 2007, 181): As in the practice of cognitive-behavioral therapy with adults, cognitive-behavioral therapy with children is (1) active, (2) structured, (3) problem-oriented, (4) collaborative, and (5) strategic. Basically, it is founded on a cognitive-behavioral conceptualization of variables sustaining the problems of an individual. Ellist (1962) and Beck (1976) are widely recognized as the pioneers of the notion of ‘cognitive restructuring’ (as cited in Reinecke et al., 2006, 6). This concept denotes the application of Socratic questioning—a process where in the individual is encouraged to find answers to their own questions through self-reflection or rational argumentation—to cure maladaptive or ‘damaged’ thinking. This model was then improved, and afterward used in the treatment of anxiety and depression in children and adolescents. Other CBT methods that were developed are adaptive self-statements, guided imagery, rational problem-solving, and training in social perspective taking and relaxation (Reinecke et al., 2006, 6). These CBT methods may be performed depending on the particular or special requirements of the child. Furthermore, CBT interventions have been designed to reduce cognitive problems. These interventions are specifically designed to promote the development of self-reflection, rational problem solving, and self-control. Almost all of these interventions, such as social problem-solving methods, reinforcement of self-regulation abilities, and cognitive restructuring, were originally designed to alleviate emotional problems among adults (Dossey & Keegan, 2012). These interventions should be adjusted for application to children and adolescents because children normally are deficient in cognitive, linguistic, and social skills to gain from these interventions if they are carried out in its original or unadjusted form. For instance, school-age children are usually incapable of differentiating and categorizing emotional conditions or to easily discern their feelings and thoughts (Reinecke et al., 2006, 7). Similarly, young children seem to be less capable than adults to remember emotions except for the environmental occurrences that created them. The application of Socrates questioning and Dysfunctional Thought Records (DTRs)—common interventions used with adolescents and adults—are, consequently, not viable with these young children (Reinecke et al., 2006, 7). Nevertheless, CBT with children and adolescents needs more than the adjustment of interventions designed for application to adults. Instead, according to Abela and Hankin (2007), cognitive-behavioral theories of psychotherapy and psychopathology have to be re-designed in terms of developmental factors. Interpersonal Psychotherapy Interpersonal psychotherapy was originally designed as a focused, time-controlled treatment of depressed non-bipolar adults. The primary objectives of interpersonal psychotherapy are to enhance interpersonal skills and to reduce depressive syndrome (Klerman & Weissman, 1993). This therapy is based on the idea that the emergence of clinical depression takes place in an interpersonal and social setting and that the occurrence, reaction to treatment and results are partly determined by the interpersonal relationship between the depressed individual and significant others. Within the interpersonal psychotherapy model clinical depression is theorized as having three aspects: (1) personality, (2) social functioning, and (3) formation of symptoms (Klerman & Weissman, 1993, 7). Interpersonal psychotherapy mediates in the latter two components but it does not suggest having an effect on the permanent features of personality (Klerman & Weissman, 1993, 7). The interpersonal psychotherapy focuses on four definite interpersonal issues: (1) interpersonal problems, (2) grief, (3) role transitions, and (4) interpersonal conflicts (Markowitz & Weissman, 2012, 398). The therapy normally puts emphasis on one of these issues. Interpersonal problems would be detected when an individual shows or reveals poor interpersonal relationships as regards to quality and number. In numerous instances the therapist and patient will have to concentrate on their therapist-patient relationship and earlier relationships. In the latter, frequent issues should be diagnosed and connected to existing situations. In applying the therapeutic model, the therapist tries to detect pathological functioning taking place like aggression, problems in building or sustaining relationships, failure to initiate intimate relationships, or extreme dependency, and will try to change these within the therapeutic approach as well as by carrying out new methods of building new relationships (Markowitz & Weissman, 2012, 398-399). Thereby, the therapeutic relationship can function as a guide for more relationships, which the therapist will encourage the patient to do. Grief is basically described in interpersonal psychotherapy as the feeling of loss by death of a loved one or significant other. The process of grieving can be problematic by being excessive, prolonged, or by turning into a chronic reaction. The therapist aids by recreating the relationship of the patient with the departed, aiding the patient in dealing with unsettled concerns in the relationship, associating the depression to the sentiments for the departed as well as by compassionate listening or empathic interaction to ease the process of grieving (Gabbard, 2005). A major goal of the grief intervention is to guide the patient in strengthening their emotional support mechanism and building new relationships. Role transitions are circumstances where in the patient must adjust to an alteration in life situations. These could be relationship failures, adjustments after life episodes, changes in social or work environments, or developmental problems. In people who experience depression, such transitions are felt as losses and thus reinforce the emergence of psychopathology (Markowitz & Weissman, 2012). Interpersonal psychotherapy tries to ease the difficulties of role transition for a patient by reevaluating the old and new responsibilities or tasks, determining the roots of problem in the new role, and creating and applying solutions to such problems. As outlined by Markowitz and Weissman (2012), appropriate treatments involve connecting the patients’ emotions to the problematic transition, identifying the potential negative and positive outcomes of the new role, improving of abilities required to feel more self-assured and productive in the new role, and performing these abilities and using them in their important relationships. Interpersonal conflicts are inclined to arise in work, social, family, or marital contexts. They can be viewed as a condition where in the patient and other involved individuals have conflicting beliefs or expectations of circumstances and this divergence is serious enough to result in major distress (Wheeler, 2008). In such situations, interpersonal psychotherapy would try to identify how problematic the conflict was and determine the roots of dispute by way of unsound or irrational expectations and defective communication (Markowitz & Weissman, 2012). The therapist attempts to mediate by problem solving, communication enhancement, or other methods that initiate adjustment in the condition. Clinical studies have strongly confirmed the success of interpersonal psychotherapy in the treatment of depressive symptoms in adults. The therapy has also been applied to other vulnerable populations such as couples, elderly, and for different forms of psychopathological conditions, and as a secondary treatment for bipolar disorder (Klerman & Weissman, 1993). The methods of interpersonal psychotherapy are performed in three treatment stages. The first stage involves psychiatric background/history and diagnostic assessment and establishes the structure for the treatment. The therapist classifies the patient as depressed by established standards, looks at sets of symptoms, and assigns the patient the sick role. During the preliminary stage, the psychiatric background comprises the ‘interpersonal inventory’—an assessment of the existing close relationships and active social functioning of the patient (Klerman & Weissman, 1993, 207). This assessment builds a structure for analyzing the interpersonal and social setting of the onset and continuation of depression and determines the emphasis of treatment. In the second stage, the therapist carries out methods which are unique to the selected interpersonal issue (Wheeler, 2008). According to Carr (2008), the last stage of interpersonal psychotherapy, usually the final weeks of treatment, motivates the patient to appreciate and strengthen therapeutic benefits and to create defenses against depression should they occur at some point. A Comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy Numerous studies strongly confirm that CBT and interpersonal psychotherapy are successful intervention approaches for general depression. CBT, as previously mentioned, is rooted in the assumption that the way an individual views an episode influences how they will react both behaviorally and emotionally. CBT assists patients in recognizing and correcting negative assumptions and detrimental thoughts to mitigate distress and strengthen coping mechanisms (Friedberg & Fidaleo, 1992). Interpersonal psychotherapy, on the other hand, is a manual-based, well-organized, short-term psychotherapy that deals with interpersonal problems in depression, like delayed grief, social seclusion, or role conflicts (Gabbard, 2005). In a nutshell, CBT focuses on negative, problematic thoughts linked to depression, and interpersonal psychotherapy deals with traumatic or stressful interpersonal and social relations linked to onset of depression. There are a number of similarities and differences between CBT and interpersonal psychotherapy. Both CBT therapists and interpersonal psychotherapists are involved participants in the intervention strategies to orient the treatment on the diagnosed deficit and to collaborate with the patient to eliminate the symptoms linked to depression. They both adopt a technique of both detailed and open-ended interview to guide the patient in analyzing his/her problem from another point of view and to create solutions with a certain degree of supervision and training from the therapist (Carr, 2008). CBT and interpersonal psychotherapy are similar in their focus on the ‘existing condition’ or the ‘here and now’ and on coaching and facilitating problem-solving abilities. Yet, interpersonal psychotherapy gives more emphasis on interpersonal problem-solving abilities, particularly as regards to relationship issues in comparison to CBT, which places more emphasis on problem solving as a whole (Dossey & Keegan, 2012). Nevertheless, in helping patients, a CBT therapist also could devote substantial amount of effort and time on interpersonal problem-solving concerns. One of the most major differences between CBT and interpersonal psychotherapy is that the CBT therapist focuses on cognition to modify behavior and mood, whereas the interpersonal psychotherapist aims to change behavior and mood. Furthermore, interpersonal psychotherapy determines one of four interpersonal issues (e.g. interpersonal problems, role transitions, interpersonal conflicts, grief) from which to address depressive symptoms interpersonally, a process not applied in CBT (Carr, 2008). Even though interpersonal psychotherapy and CBT address depressive symptoms within these dissimilar and distinctive frameworks, both are two time-restricted interventions that have commonalities and several basic dissimilarities. Interpersonal psychotherapy is a widely recognized cure for depression and has been reported to be successful in numerous studies. A current meta-analysis discovered that it was better than placebo, comparable to medication and, in combination with medication, did not exhibit a secondary outcome in comparison with medication only for prophylactic treatment, maintenance, or acute treatment (Carr, 2008, 152). Even though the meta-analysis discovered that interpersonal psychotherapy was more effective than CBT, other researchers claim that interpersonal psychotherapy is similar to CBT as regards to effectiveness. The same findings were made public by the Sheffield Psychotherapy Project. In this study, 120 depressed individuals in the United Kingdom were distributed to at least 8 sessions of CBT or interpersonal therapy (Gabbard, 2005, 224). Both interventions were discovered to be similarly successful and to manifest their outcomes with the same speed. Patients who were experiencing mild depression had the same result irrespective of the duration of the therapy. Nevertheless, in patients who were experiencing severe depression, radically effective results were observed when longer duration of therapy was given, regardless of whether the intervention method was CBT or interpersonal psychotherapy (Gabbard, 2005, 224-225). Longer durations of therapy did seem to be linked to superior enduring results, specifically as regards to interpersonal psychotherapy. Relevance of CBT and Interpersonal Psychotherapy in Nursing Practice CBT has been used in various adult disorders in various contexts. Moreover, CBT has been given growing recognition in child psychology. In addition, CBT in inpatient contexts is a developing field. These patterns show that CBT is a flexible and successful treatment to a broad array of human disorders. The possible success of CBT in mental hospitals is reinforced by a situation where in nurses put into practice a theoretically similar framework (Dossey & Keegan, 2012). When nurses share a similar conceptual or theoretical perspective and use similar nursing terminologies, treatment tends to progress more efficiently. Perris (1988), promoting a CBT setting, stated that “a common view and a common language counteract the fragmentation experienced by patients admitted to wards where different ideologies may be competing” (as cited in Friedberg & Fidaleo, 1992, 1). Expert nurse training builds the internal strength of this theoretically uniform framework. The roles of nurses have evolved tremendously over time—from caregiver to mentor, leader, and therapist. Peplau’s (1952) widely recognized suggestion that nurses have to gain knowledge of and practice therapeutic strategies that assist patients in identifying and understanding their condition is now universally established (as cited in Pothier, 1980, 3-4). As stated by the American Nurses Association (1976), modern mental health and psychiatric nursing requires the following central components (as cited in Pothier, 1980, 4): (1) the application of theories of human behavior as part of the science and art of specialized nursing practice; (2) use of these skills to achieve both corrective and preventative effects on mental disorders; and (3) promotion of optimal mental health for individuals, the community, and society. Several scholars have stressed the need to develop a sound theoretical framework to lead nursing practice. It has been reported that the use of CBT within a hospital setting offers a useful guide for nursing practice. This claim has been substantiated by the findings of a number of current controlled clinical studies. Moreover, CBT agrees with numerous generally held ideas and theories of mental health nursing in relation to the cause and treatment of psychological problems (Carr, 2008). Several major ideas about the relevance of CBT in nursing practice are outlined below. First, mental health nursing is focused on identifying and understanding abnormalities in a patient’s behavior, emotions, and thoughts as well as what really has occurred in an individual’s life. The nurse builds a therapeutic relationship with the patient to resolve these issues in a proactive, scientific, and collaborative way. Second, the patient’s emotions and thoughts signify reactions to both external and internal stimuli. Such emotional and cognitive reactions have a tendency to arise continually, influencing the individual’s behaviors or actions (Carr, 2008). Third, the nurse’s assessment of a patient’s behavior and mood on the hospital can be broadened to involve documenting/recording, discussing, and examining what the individual is feeling and/or thinking. Guiding the patient in making his/her judgments or interpretations about the significance of events will support this assessment. Fourth, CBT is a useful strategy to correct maladaptive behavioral, emotional, and cognitive processes (Friedberg & Fidaleo, 1992). Employing CBT, the nurse promotes effective adjustment to stressful circumstances in the individual’s life. Similar to all successful therapists, the mental health nurse is most effective when s/he has the capacity to help the patient concentrate on understanding and correcting emotional problems and dysfunctional behaviors. Fifth, even though not successful in all cases of psychological problem CBT methods have been confirmed to be successful in particular populations, especially those experiencing depression and anxiety (Friedberg & Fidaleo, 1992). Sixth, CBT methods can be applied with certain levels of success in both group and individual therapies. And lastly, mental health nurses should be given expert training so as to apply this type of treatment successfully. Likewise, interpersonal psychotherapy is a valuable intervention strategy in nursing practice. Interpersonal psychotherapy has a number of features that make it a valuable component of psychiatric nursing practice. First, findings strongly confirm the success of individual interpersonal psychotherapy for several specific treatments intended for specific problems. Second, numerous of the methods of interpersonal psychotherapy are of importance to nurses in their everyday tasks. Third, interpersonal psychotherapy has possible value to all contexts or environments where in mental health nursing is performed: home care, outpatient, and inpatient. And fourth, interpersonal psychotherapy has focused on short-term treatment methods that diverge considerably for the earlier model of psychotherapies (Wheeler, 2008). It is crucial for nurses to gain accurate knowledge on how psychotherapies vary in order for them to guide patients in selecting correct therapies. In a period where in professional and public discourses provide emphasis on the function of medications to mental disorders and there is continuously growing focus on genetic or biological explanation of psychological disorder, it is crucial to understand that CBT and interpersonal psychotherapy are still valuable and highly proven therapeutic interventions. A lot of patients are treated through procedures that encourage them to develop ideas, to understand their own behaviors and thoughts, and to explore new ways of interaction and relationship-building. Nurses in almost any domain of practice will come across certified therapists who recommend a variety of treatment models. Each treatment intervention has its strengths and distinctive advantages. Patients may normally consult nurses about the benefits of specific treatment methods. Implementation of Advanced Practice in Interpersonal Psychotherapy Several nurses in advance practice work as therapists. These nurses have supplementary training in individual therapy, and numerous have undertaken treatment themselves as a way to understand their personal and professional actions. Yet, other nurses could use particular psychotherapeutic methods to help patients in every clinical environment. For instance, a nurse could employ the interpersonal psychotherapy model to provide an account of how s/he thinks patient is dealing with the disorder (Carr, 2008). CBT methods that help the patient identify and understand his/her thoughts could be applied, too. For instance, instructing the patient to name something encouraging about his/her performance at work, instead of focusing on negative aspects, could be the initial step for the patient to understand his/her thought patterns about him/herself. Nurse psychotherapists enjoy the privilege of getting involved in the treatment process, and as emphasized by Dossey and Keegan (2012), in the relationship between the nurse and his/her patient, the former becomes “the patient’s environment” (p. 113). By means of presence, purpose, and awareness, the nurse psychotherapist helps others in their treatment. To counteract the acquired guidelines of nursing practice, such as control and task orientation, the nurse psychotherapist has to foster persistence, consciousness, and reflection. The nurse psychotherapist builds a treatment environment of total empathy, sincerity, understanding, unbiased attitude, fortitude, and acceptance (Dossey & Keegan, 2012). These attributes are the spirit of presence and enable the nurse psychotherapist to get truly involved in the patient’s treatment. According to Gabbard (2005) and Dossey and Keegan (2012), presence could enable healing by changing detrimental emotions by strengthening hormones and neurotransmitters that creates the most favorable autonomic processes. Attributes fundamental for nurse therapists involve broadening of awareness and carrying on with one’s personal struggle toward fullness. This can be achieved through several different domains: reflective activities like walking, willingness to receive own treatments, spiritual habits, self-awareness practices, meditation, counseling, and relationships (Wheeler, 2008, 10). These practices help the nurse improve the growth of sincerity, patience, and consciousness. Peplau (1991) emphasized the importance of self-consciousness in the nurse-patient relationship within interpersonal psychotherapy and argued, “The extent to which each nurse understands her own functioning will determine the extent to which she can come to understand the situation confronting the patient and the way he sees it” (as cited in Wheeler, 2008, 10). Self-consciousness is a valuable tool in understanding others, and it lessens the possibility that nurses will serve their own interests and take advantage of patients for self-confidence or fulfillment needs. Other than self-consciousness, self-care is essential in interpersonal psychotherapy. A great deal has been reported about the stress and trauma innate in nursing. Different terminologies have been introduced to illustrate this trend, like compassion fatigue and burnout (Wheeler, 2008). It is only through the acceptance of one’s personal trauma that nurses can surpass it and be of guidance and assistance to others. Conclusions Professional nursing practice ever more obliges nurses to understand and approach their jobs theoretically. Hence, it is sensible to analyze the relevance of CBT and interpersonal in the principle of nursing theory. Interpersonal psychotherapy distinguishes anxiety, conflicts, depression, disappointments, and needs as major components that a nurse must openly and thoroughly assess in the point of view of a patient’s history and current situation. CBT is in agreement with nursing theories putting emphasis on adjustment. An important attribute that nurses should have is a problem-solving, experiential framework applying the nursing process as a general structure for practice. The problem-solving method required in CBT and interpersonal psychotherapy is similar to the nursing procedure. Both require an evaluation, diagnosis, and intervention. Both CBT and interpersonal psychotherapy are based on a health-focused, problem-solving systemic framework and are valuable and indispensable to nurse-patient relationship and nursing practice. References Abela, J. & Hankin, B. (2007). Handbook of Depression in Children and Adolescents. New York: Guilford Press. Carr, A. (2008). What Works with Children, Adolescents, and Adults: A Review of Research on the Effectiveness of Psychotherapy. New York: Routledge. Dossey, B. & Keegan, L. (2012). Nursing: A Handbook for Practice. Burlington, MA: Jones & Bartlett Publishers. Friedberg, R. & Fidaleo, R. 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