This section focuses on how you can use aspects of cognitive behavioural ap- proaches in your communication with people for whom you care. In Table 2.3 we outlined the core attitudes, values and skills required in developing, main- taining and ending therapeutic encounters. These are also important in using cognitive behavioural approaches in your everyday practice. We recommend you refer to Chapters 2 and 7.
We will now focus on four different aspects of cognitive behaviour ap- proaches:
1 the five areas approach 2 behavioural activation, 3 cognitive restructuring 4 problem solving.
The five areas approach
The five areas model is an approach to assessment using cognitive behavioural principles that Chris Williams and colleagues (Williams and Chellingsworth, 2010) at the University of Glasgow developed. The five areas approach adheres to the traditional cognitive behavioural approaches of showing how thoughts, feelings and behaviours interact in developing and sustaining dysfunctional anxiety and mood disorders such as depression. It is an approach that can be incorporated with relative ease into the day-to-day practice of mental health nursing. Figure 10.2 illustrates the five areas approach.
We shall demonstrate how you can use this approach with someone for whom you are caring.
Practice exercise
Susan is a 38-year-old mother of two young children who has been referred to your mental health team by her GP who believes she is anxious. She has been allocated to your caseload. You are conducting as assessment interview with Susan, during which you use the five areas approach. The following illustrates how you can use this approach.
1 Ask Susan to identify a specific and typical situation where she has recently felt highly anxious. She reports a sudden phone call from her husband to say he must remain at work and requesting Susan to pick up the children from school. Susan has not done this for some time and recalls feeling highly anxious when she did this because she felt the other parents were talking about her in a negative manner.
2 Having identified the specific situation, ask Susan to record the altered thinking associated with this situation. For example, this might include ‘I thought I was a bad mother.’
Situation
Altered thinking
Altered physical symptoms Altered
feelings Altered
behaviour
Figure 10.2 The five areas approach to assessment
3 Ask Susan to record physical symptoms associated with the situation. These may include feeling hot, flushed, sweaty and panicky.
4 Ask Susan to identify altered feelings associated with the situation. For example, these may include feeling anxious.
5 Finally, ask Susan to record altered behaviour linked to the situation. This may include refusing to leave the house because of the anxiety.
There are several benefits to using the five areas approach.
r It helps you capture important information about a client’s thoughts, feel- ings and physical symptoms, and how these influence behaviour.
r It gives you a structure to your assessment.
r It involves the client actively.
Having used the five areas approach in your assessment, you may use some cognitive behavioural approaches as a treatment. We describe four such ap- proaches below, starting with behavioural activation.
Table 10.3 Six steps in using behavioural activation (from Richards and Whyte, 2009)
Six steps Mental health nursing activities
Step 1: Explain BA, e.g. BA is an intervention that helps people re-create everyday routines and increase activities that give them pleasure
Key things to communicate to David are the relationship between physiological, cognitive and behavioural symptoms, how avoidance sustains low mood, and how routine, pleasurable and meaningful activities can change things
Step 2: Identify routine, pleasurable and necessary activities
Ask David to identify things that he would normally do if he were not depressed Step 3: Make a hierarchy of routine,
pleasurable and necessary activities
Ask David to rank the activities identified in step 2 in order of importance: low, medium and high priority Step 4: Plan some routine, pleasurable
and necessary activities
Help David plan routine, pleasurable and meaningful activities starting with the lowest ranked initially. This could form the basis of a week of planned activities that David can record in the form of a diary
Step 5: Implement BA exercises, i.e.
participating in the routine, pleasurable activities
Help David carry out the planned activities and ask him to make a list of the activities he does, for example taking the dog for a walk, visiting a friend, listening to music Step 6: Review progress Review progress with David by asking him
to list those activities he managed to complete
Behavioural activation (BA)
BA is a structured psychological intervention that is often used as part of CBT, but has an increasingly strong evidence base when used on its own (Richards, 2010). The effectiveness of BA derives from it usefulness in targeting avoidance in people with depression (Richards and Whyte, 2009). Essentially, BA is an intervention that helps people re-create everyday routines and increase activi- ties that give them pleasure. Mental health nurses are well placed to use BA in day-to-day work. Table 10.3 outlines the six steps of BA and we show you how to use these steps when working with people in your care, using David as an example. David is a young man living with depression who you have taken on to your caseload in your role as a nurse in an early intervention team.
BA focuses mostly on re-discovering behaviours, the everyday routine and pleasurable activities that have given people satisfaction, but that have been dormant as a result of depression. BA is method of working with people on behavioural change. When people are depressed they often express automatic thoughts that are unhelpful, intrusive and, although they are real to the per- son expressing them, are generally irrational and likely to perpetuate their
low mood. Cognitive restructuring is an approach that you can use to help people to modify automatic thoughts by assisting them to recognize, scruti- nize and confront them. We will now explain how to incorporate cognitive restructuring into your work as a mental health nurse.
Cognitive restructuring
Richards and Whyte (2009) identify three stages to cognitive restructuring.
We shall demonstrate how you can use these stages with David, to whom we referred in our BA exercise.
Clinical scenario
r Stage 1 – Recognizing thoughts: Ask David to identify a situation in which he felt a particular emotion. Such a situation may include failing a driving test, a job interview or a relationship breakdown. Ask him to rate the emotion on a scale of 0–10 with 0 being the weakest emotion and 10 being the strongest. Following this, ask David to write down the automatic thoughts associated with the situation, e.g. failing a driving test could lead to the automatic thought of being a failure as a person. Help him to pin down the most salient thought, the so-called ‘hot thought’, and the one causing the greatest distress. Finally, ask David to identify the strength of his belief in the hot thought from 0, little belief, to 10, the strongest belief.
r Stage 2 – Search for the evidence: Ask David to choose an automatic thought to work on, usually the ‘hottest thought’ with a rating of at least 6 out of 10. For this thought, ask David to write down the evidence for and against this thought.
For example, David’s hottest thought is ‘I am a failure as a person, that’s why I failed my driving test.’ Ask him to write down what evidence leads him to this conclusion.
Now ask him to write down evidence to challenge this conclusion. For example, ‘I failed my driving test because I did not prepare enough. I have succeeded at things for which I have prepared.’ This approach allows for a more balanced assessment of the conclusion.
r Stage 3 – Restructuring thoughts: Help David to re-examine the automatic thoughts in light of the evidence identified in stage 2, write down new thoughts and consider the feelings associated with the new thoughts. For example, having re-examined the evidence, David is likely to put the driving test failure into context in light of his success at other things and will thus feel better. Then ask David to rate his strength of belief in each new thought from 0–10. Finally, help David to recognize how his feelings may change after having identified new thoughts.
Having considered the value of helping people to modify automatic thoughts by assisting them to recognize, scrutinize, confront and challenge these thoughts and thus recover from depression, we now turn our attention to what is a common-sense approach to dealing with overwhelming problems: problem-solving interventions.