Who said cognitive behaviour therapy was only about mental health?

Nurses explain how they use CBT to support the well-being of patients with physical conditions

• Principles of cognitive behaviour therapy (CBT) dovetail neatly with those of holistic nursing care 
• Read how a respiratory nurse uses CBT to support depressed and anxious patients, and has cut hospital admissions 
• Discover how nurses can apply CBT interventions in physical health settings

Cognitive behaviour therapy (CBT) is a ‘talking treatment’ that exploits the connection between how we think and how we behave.

It is a well-established therapeutic approach to a range of mental health issues and is increasingly used to address the psychological components of physical health conditions such as respiratory disease, diabetes and irritable bowel syndrome.

So how can I use CBT in my nursing practice?

Nurse and CBT therapist Emma Forbes, who practises in the NHS and privately, says: ‘The concept is that what we think affects our feelings, behaviour and physical sensations.

• RELATED: Using CBT to improve self-awareness and resilience

'All those aspects are linked. By identifying what our negative thoughts or negative thinking patterns are, we can improve how we feel.’

The relationship between what we think and how we behave

Mental health charity Mind explains that CBT combines cognitive therapy – examining what you think – and behavioural therapy – examining the things you do.

The charity states: ‘It is based on the theory that how we think about a situation will affect how we feel and, as a result, how we behave.

'For example, negative thinking patterns fostered since childhood through the absence of praise or attention may cause an individual to think "I’m useless".' 

‘CBT delivered by respiratory nurses reduced patients’ symptoms of anxiety, helped their mood and quality of life – and massively slashed emergency attendance’

Karen Heslop-Marshall, nurse consultant, Royal Victoria Infirmary, Newcastle

By adulthood, these responses may be ingrained and automatic, and can affect how the person feels at work or in relationships.

In cases like these, CBT may help the individual to consider such responses more closely and introduce ways of turning them round, thereby dealing with issues such as low self-esteem.

Similarly, when depression or anxiety is associated with a long-term physical condition and is causing isolation, for example, CBT can help the individual reframe the psychological impact of ill health and generate behavioural changes.

Tell me about the evidence base for CBT

First of all, CBT does not always work but there is a wealth of data suggesting it can help for a range of conditions and in a wide variety of client groups.

The National Institute for Health and Care Excellence (NICE) online repository of evidence demonstrates CBT’s broad applicability.

‘Some critics argue that because CBT only addresses current problems and focuses on specific issues, it does not address possible underlying causes of mental health conditions, such as an unhappy childhood’

NHS, Health A-Z

Studies listed by NICE show CBT’s effectiveness in conditions that include: anxiety, depression, chronic fatigue syndrome, autism spectrum disorder, violent behaviour in children, phobia and panic disorder, hoarding, attention deficit hyperactivity disorder, headaches and migraine, non-opioid drug use, fibromyalgia, chronic physical illness, tinnitus, even schizophrenia.

• RELATED: Breast care nurses trained in CBT to help treat hot flushes

Ms Forbes says: ‘There’s been a lot of work done with people with psychotic symptoms and, for example, how CBT can help manage voices. So if you have a diagnosis of schizophrenia, CBT may be suitable for you.’

A randomised controlled trial conducted by nurse consultant Karen Heslop-Marshall provided evidence that CBT can reduce feelings of anxiety in patients with COPD and lead to less frequent use of emergency and hospital services.

By treating patients’ mental health, their physical well-being improved

When Karen Heslop-Marshall, a nurse consultant at Newcastle’s Royal Victoria Infirmary, was studying for a master’s degree in the late 1990s, she interviewed patients about living with chronic obstructive pulmonary disease (COPD).

‘Obviously, breathlessness was a big problem but anxiety and depression also came up a lot, and I thought as a respiratory nurse I can’t help with that. At the time I didn’t have any skills in that area but it sparked my interest,’ says Dr Heslop-Marshall.

She went on to learn the basics of cognitive behaviour therapy (CBT) and undertook a foundation course with a postgraduate diploma in CBT.

Applying CBT to support individuals who were depressed or anxious

She incorporated CBT into her practice, with patients referred to her if they scored high on an anxiety and depression screening questionnaire or were experiencing panic attacks or low mood.

‘The consultants were saying we need to show this works,’ she says, so she applied for funding to undertake a randomised controlled trial.

Research project revealed clinical benefits and cost-effectiveness

In the trial, published in ERJ Open Research, half the patients were given self-help leaflets and half were given leaflets but also saw nurses trained to deliver CBT. Patients who received CBT did better than those only given the leaflet.

The study concluded that a brief CBT intervention, delivered by respiratory nurses, was beneficial to patients and cost-effective.

• RELATED: Adult nursing degree straddles blurred boundaries of physical and mental health

‘It reduced their symptoms of anxiety, helped their mood and helped their quality of life,’ says Dr Heslop-Marshall.

‘The skills to apply CBT should be in the curriculum for nursing students’

'But it also massively slashed hospital admissions and attendances in accident and emergency.’ 

She screened more than 1,500 patients with COPD as part of the study and almost 60% had symptoms of anxiety.

The role of depression in COPD mortality

Anxiety and depression are ‘absolutely massive’ problems that affect the mortality of patients with COPD, says Dr Heslop-Marshall. ‘If you’re depressed and have a physical health problem, you’re more likely to die sooner.’ 

All nurses should be trained to apply CBT principles, she argues.

‘These skills should be in the curriculum for nursing students, but also for student physios and occupational therapists, because they can be used in the physical health setting.’

Let’s talk about the limitations of CBT

The British Association for Behavioural and Cognitive Psychotherapies (BABCP), which offers accreditation for CBT practitioners, emphasises CBT is not a quick fix. Its literature states: ‘It involves hard work during and between sessions.’ 

It also requires the individual to have the motivation to change, and if a person is depressed, summoning that may be difficult. Likewise, overcoming anxiety means confronting it. ‘This may lead you to become more anxious for a short time,’ the Royal College of Psychiatrists (RCPsych) suggests. 

 ‘As nurses, we’re great observers and by knowing your patient you will notice any changes in them’

Emma Forbes, nurse and cognitive behaviour therapy practitioner 

In addition, the NHS notes: ‘Some critics argue that because CBT only addresses current problems and focuses on specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood.’

Ms Forbes says CBT is not appropriate for someone who is acutely suicidal or has complex mental health needs.

• RELATED: CBT delivered by nurses proves effective in reducing anxiety

‘Sometimes I’ve suggested someone should see a psychiatrist before I see them again because the risk is too great for me to hold on my own,’ she says. ‘That’s about me being responsible and recognising that risk.’

How is the therapy delivered?

CBT can be offered individually or in a group context. According to the NHS website, sessions are usually weekly or fortnightly and typically run for between five and 20 sessions, each lasting up to an hour.

Unlike psychoanalysis, which may continue for years, CBT’s duration is defined by goals agreed by therapist and client.

The RCPsych explains that during the sessions, the therapist will help the client ‘notice any patterns in thinking or behaviours that might keep problems going’.

Ms Forbes says: ‘Together – and the collaborative process is an important tenet of CBT – you and the therapist work out what thoughts are linked with the presenting problem, how it makes you feel, how you react in terms of your behaviour and how you cope with it.’

Graded exposure as a therapeutic technique

As well as targeting negative thought cycles, CBT may involve graded exposure, particularly in cases of phobia or obsessive-compulsive disorder. Exposure therapy involves the client facing their fears in a methodical, structured way.

• RELATED: Delivering cognitive behaviour therapy in a secure setting

It begins with a situation that causes anxiety but is tolerable. After the exposure has been repeated two or three times and anxiety has not risen, the therapist will ask the client to move on to a more difficult situation and the cycle begins again.

The NICE online repository features examples where CBT has been successfully delivered online or over the phone.

How can someone access CBT?

BABCP lists accredited practitioners, so finding a local therapist is quick and easy if a client has the means to pay. Private sessions vary in cost but typically start at £40, at time of writing.

The NHS Improving Access to Psychological Therapies (IAPT) programme began in England in 2008. Fully trained and accredited practitioners deliver evidence-based treatment and clients can self-refer but there may be a waiting list.

Since last year, all clinical commissioning groups in England have been required to offer IAPT services integrated with physical healthcare pathways. However, Dr Heslop-Marshall says that a CBT-trained nurse who, like her, specialises in an area of physical illness would be able to identify health issues that an IAPT practitioner might not.

The unique effectiveness of CBT-trained nurses

Dr Heslop-Marshall cites the example of a patient she saw with anxiety relating to respiratory disease. The woman, it transpired, had a heart rate of almost 200 and was in supraventricular tachycardia.

‘I could spot that within ten seconds,’ says Dr Heslop-Marshall. 'The key to this in long-term conditions is that you have knowledge of the underlying condition as well as the CBT skills.’ 

Nurses who think patients may benefit from CBT can signpost them to their GP or to online resources such as the those offered by Mind, NHS and BABCP.

How can I apply CBT principles to make my nursing practice more holistic?

CBT training courses are usually university-based postgraduate programmes but Ms Forbes argues that most nurses can use CBT’s guiding principles in their work with patients. In fact, many may, without realising it, be doing so already.

Holistic nursing acknowledges that health comprises physical, psychological and social elements, and exploring the connections between them is at the root of CBT.

‘As nurses we’re great observers and by knowing your patient you will notice any changes in them,’ Ms Forbes says. ‘So just ask them. Use open questions such as “What’s going on with you today?” or “You seem a bit sad or anxious – is that something you’d like to talk about?”. Or if you see someone has a picture of a loved one just ask a bit about them.’

That old nursing principle of seeing the person as more than their condition

She suggests that time spent giving personal care is a good opportunity to ask personal questions. ‘All kinds of things come up.’

She adds: ‘It’s that old nursing thing about seeing someone as more than the condition they’re coming in with. You’re seeing them as a person and finding out more about them. You’re saying, “I’m open to having a conversation”.’

• RELATED: CBT strategies can help you handle stress

Humour, too, can help break down barriers between patient and professional. ‘Humour’s something we’re really good at as nurses,’ says Ms Forbes.

Clearly, there is more to CBT than opening up a conversation but doing so can be a means of identifying emotional or psychological issues that may be associated with a patient’s physical ill health.

Dr Heslop-Marshall takes this a step further by training nurses to use CBT principles. After seeing how CBT could improve the well-being of her own patients, she developed a course, Pivotal, that trains physical health professionals to treat patients using basic CBT skills and techniques.

‘People who’ve done the course over the years really love the techniques and think it’s helped their practice,’ she says.

Further information

• British Association for Behavioural and Cognitive Psychotherapies
• Emma Forbes, nurse and CBT therapist
• CBT in COPD: ERJ Open Research study
• Mind CBT information
• NHS CBT information
• Pivotal – CBT training for nurses

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