Develop a treatment Plan for the specific Implementation of CBT Interventions or Strategies.
Mental health nursing is a specialization in nursing that deals with mental illnesses and disorders in people of all age brackets. Some of these illnesses and disorders include; Schizophrenia, depression, dementia, bipolar affective disorder, and agoraphobia. There are several incidences that may lead to mental disorders. Such events may include; one losing a loved one through death, divorce, abuse of drugs and alcohol and changes that occur in one’s life for example job. It is the role of a mental health nurse to facilitate the recuperation of individuals suffering from mental disorders (Cahil, 2013). The recovery process involves the patient in activities that will help them control their specific mental conditions. In mental health nursing, CBT (Cognitive Behavioral Therapy) refers to the coordination of a person’s emotions, behavior, thoughts, and physical aspects. A CBT helps identify these interactions which later help the patient to know whether their thought and behaviors are adequate or inadequate in adapting to the world. In this paper, we are going to focus on a case study of Japan.
The case study of Japan indicated that out of all patients with mood and developmental disorders, those with Schizophrenia were the subject of the CBT. Schizophrenia occurs when an individual develops a series of problems relating to his/her emotions, cognitive ability, and overall behavior. Schizophrenia is of three types; paranoid schizophrenia, disorganized schizophrenia and catatonic schizophrenia. There are numerous symptoms and signs that are an indication of this mental disorder, but the common ones are; hallucinations, speech that is not organized and delusion (Haddock, 2014).
Patients who have Schizophrenia hallucinate. Hallucination involves hearing or seeing non-existent things. Schizophrenic persons mostly hear voices that are not normal. Speech that is disorganized which is a common sign can be identified through the way in which the patient responds to questions. They may give unrelated or even incomplete answers. Sometimes, the patient may deliver statements with words that are meaningless or difficult to understand. A delusion which occurs in Schizophrenia patients involves beliefs that are false for example the individual may take a loving gesture from another person for harm due to poor interpretation (Robson, 2013). The symptoms of teenagers who have Schizophrenia may be evidenced by; performance drop in school, lack of sleep, separating oneself from friends and lack of motivation. In a comparison of symptoms in adults, the teenagers have a less likelihood of suffering from delusion but more probable to experience seeing- related hallucinations.
The major problem for patients who have Schizophrenia is that they experience feelings and portray behaviors that are suicidal (Yoshinaga, 2017). It is therefore recommended that a family where one of the members suffers from this disorder stay in touch to make sure that the patient does not commit suicide. Other problems associated with this disorder are; self-injuries, inability to perform daily activities, aggressive character, social alienation, financial problems, legal problems and possible drug abuse. A case study of Japan that compared the level of stigmatization of mental disorders indicated that Schizophrenia was more stigmatized compared to others like depression (Williams & Bates, 2015). Most Japanese had the belief that schizophrenia patients were more dangerous than those who suffered from depression. The Schizophrenic patients were also unpredictable compared to those suffering from depression. This belief extended even to the job market where by most employers failed to employ individuals who have chronic schizophrenia. However, there was a partial exception for those suffering from early stages of schizophrenia. The statistics available showed that about60 % against 40 % of job seekers who have chronic schizophrenia and early schizophrenia respectively less likelihood of being employed.
There are four risk factors relating to mental health disorders commonly known as the 4P factors. They include; predisposing risk factors, precipitating risk factors, perpetual risk factors and protective risk factors. Predisposing factors make an individual more prone to a certain mental disorder. A perfect example of a predisposing factor is a family history whereby schizophrenia is present (Happell, 2013). This increases the probability of family members to suffer the mental disorder. On the contrary, in a family where the disorder is not present in the history, the family members are less likely to suffer from the disorder. The precipitating factors are a series of precipitating events that increase susceptibility thereby contributing to a mental disorder. Some of the precipitating risk factors include; stressor, catastrophe, and stress related to adopting a new culture. One unique property about precipitating risk factors is that they occur before the disorder. Different people react differently to a similar precipitating event which is dependent on one’s background and life experiences.
The third risk factor, perpetual risk factor has a role in the prevention of recovery from a mental disorder. These risk factors contribute to progressive worsening of the patient’s symptoms. Perpetuating risk factors may include predisposing and precipitating factors that are not resolved, continuous bullying, social isolation, poor personal skills and low resilience to challenging life situations. The last factor in the 4P factor model is the protective risk factor which prevents or reduces the probability of occurrence of a certain mental disorder (Butler, 2014). A perfect example is a disorder in substance use could be prevented by not using the substance. Some protective factors may be generic for example good relationship with friends and family, personal attributes such as self-confidence and support from the society. Cognition plays a key role in the maintenance of mental disorders and symptoms. The major cognitions the effect mental disorders are; emotion cognition and motor cognition.
Emotional cognition may lead to conditions such as depression and anxiety since for these disorders to occur there has to be dysfunction in cognition and bias in the processing of information. This contributes to starting and maintenance of a series of ceaseless symptoms. An anxiety literature indicates that those people who are anxious show little ability to regulate their emotions as reported by Yoshinaga (2015). Additionally, people who are anxious orient to harmful changes in the environmental very fast and hardly get out of the harmful situations. This difficulty to come out of the threatening stimuli plays a key role in the maintenance of anxiety as a mental disorder. This is what is referred to as attention bias. Attention bias may also occur in depression if an individual is exposed to changes in the environment for a long period. This is contrary to the literature of anxiety whereby the stimuli only covered short durations (Videbeck, 2013). A comparison reveals that attention bias in anxiety is an indication of the initial stages of processing whereas in depression it is an indication of later processing stages. From findings, it is right to deduce that depression and anxiety are products of abnormal cognition which is contributed by distractions in the environment.
Interpretation bias is also brought by up by anxiety. Interpretation bias is supported by two major f MRI findings namely; PFC and responsivity of the amygdala. The PFC involves the process of developing a new interpretation of certain life situations. It is through an individual’s effort to regulate emotions in an attempt to reduce the information that is negative where new interpretations arise. In the responsivity of the amygdala, anxious people over-interpret neutral stimuli and consider them harmful. One of the negative effects of interpretation bias is memory loss. It is not clear whether interpretation bias is related to depression.
Apart from the earlier discussed emotional cognition, motivation cognition also plays a role in the maintenance of mental disorders and symptoms. Studies on psychophysiology and behaviors show that motivation has an active role in depression as reported by (Melynk B M, 2014). Deficits in motivation can be showed through poor response to environmental changes that are positive. Apart from these deficits, depression could also be attributed to avoidance of a certain behavior and hypersensitivity to punishments and chaos. There is a tendency with depressed individuals of responding abnormally to punishments and difficulty with coping with feedbacks that are negative. Motivation literature states that abnormality is not only an issue affecting people suffering from depression but also those suffering from anxiety.
A study on the knowledge about recovery and treatment of schizophrenia showed general pessimism towards recovery from such a disorder. However later, an approximated percentage of 80% of people agreed that it was possible for the disease to be treated. It was also essential to note that out of the 80% of the public, only 40% who believed that full recovery would be possible (Robson, 2013). Adherence to medication for this mental illness was poor. This was related to lack of knowledge about the possible side effects of the illness. A similar study showed that a majority of the public did not acknowledge the psychiatrist help as a solution to full recovery. In any case, they recognized antipsychotics as persons of big help. In the stigmatization study, demographic characteristics were also considered especially age. Sex as a demographic characteristic did not have any regard. The study showed that older people were more pessimistic to schizophrenia and other mental disorders compared to younger people (Struthers, 2015). This attitude may be attributed to inappropriate education, lack of opportunities for people suffering from mental illnesses and negative social perception of mental illness.
The treatment of schizophrenia is based on CBT principles. In the treatment process, thoughts, emotions, and behavior are integrated. In the treatment plan, agendas are proposed and more flexible. It is important to note that in the traditional CBT agenda are not flexible. The period of recovery is different depending on the patient’s need. Normally, there are 12 to 20 sessions in the plan alongside other sessions that act as boosters. The CBT occurs in a series of steps which are; assessment, engagement stage, goal setting, normalization, critical collaborative analysis and finally the development of alternative explanation.
In the assessment phase, the therapist actively listens to the patients as they share their thoughts based on their life experiences. This stage is monitored using scales of rating precisely the general and specific scales (Stevens, 2013). Any remarkable progress made by the patient through the monitor process is shared by the nurse to the patient. Other aids that are used in this stage are diagrams for those patients with a lifestyle that is disorganized. Additionally, information about symptoms, causes, and possible maintenance is shared with the patient.
The second phase involves engagement whereby questions meant to pursue thoughts are applied. The Socratic questions gauge an individual’s ability to understand his/her mental condition and the readiness to adapt to the world by coping with the condition (Townsend, 2014). The therapist tries to understand the specific distress and emotions of the patient in an empathetic process. This is a gesture to allow flexibility with the patient. The therapist then develops a vulnerability-stress model to educate the patient on the dynamic nature of vulnerability. In this model, vulnerability is attributed to some factors including; incidences taking place in life, physical illness and ability to cope. The therapist does not have the answers to all situations, but there is room for explanations if the patient cooperates. Some of the most important therapeutic aspects that are applied in this phase are; humor, transparency, warmth, and empathy. Alternatively, an ABC model can be applied. This model helps the patient to pick up the pieces by reordering experiences that are confusing as stated by Cahil (2013). The steps taken in an ABC model include; the therapist gives a rating of patient’s distress, assessment of the consequences accompanying distress categorically based on emotions and behaviors, a patient’s explanation of the possible causes of the consequences, feedback with the knowledge of A-C connection. The therapist then makes the patient believe that the A-C model lacks a personal meaning and in the final stage the belief of the patient is discussed and a feeling of acceptance is created.
The third stage in a treatment plan involves goal setting. Goals set in in the therapy are realistic to the patient and the therapist. Distressing consequences are used to promote the changes needed to achieve the set goals (Haddock, 2014). At the beginning and end of the therapeutic process, the goals are reviewed. Normalization is the fourth phase of the treatment plan. In this phase, the therapist makes it clear to the patient that unusual experiences can occur to anybody due to experiences such as hunger, thirst, torture, stress, and hyperventilation. By gaining this understanding, anxiety reduces, and the patient develops a sense of belonging and social acceptance. This normalization of psychotic experiences enhances fast recovery among patients.
A critical collaborative analysis forms the fifth phase of a treatment plan. The onset of this stage is often indicated or marked by the trust which was created between the therapist and the patient. In this stage, Socratic questions asked by the therapist are gentle which allows the patients to make personal deductions on the logic of positive psychotic change (Fortnash, 2014). The test to eliminate beliefs that slow down the rate of adapting to the world is conducted in distress free manner. This is only possible if the therapist is empathic, transparent and non-judgmental. In a homework setting, the misattributions identified are reattributed. This is done through cognitive distortions, for example, emotional reasoning and revisiting of antecedents like trauma which form the foundation for psychotic change to happen. The final stage in a treatment plan is the development of alternative explanation whereby patients are allowed to bring out the coping strategies in mind other than the methods suggested by their therapists (Zugai, 2015). This is important since the explanations offered by the therapist may not suit some patients.
A perfect real-life example of patients who benefited from CBT is the story of Jasmine, a 52 years old lady who had been suffering from schizophrenia for 31years. She had been hearing voices that were not existent for the 31 years following a bomb blast incident that she survived as a teenager. Jasmine had never accepted schizophrenia diagnosis but had been adhering to medication. She also complied with CBT with the argument that she enjoyed speaking the therapist who was a young and warm-hearted man. In the assessment stage, it was evident that the main problem of the patient was a lack of confidence and isolation from family and friends with the belief that the voices had an external source.
The engagement phase was less problematic. In the first attempt, the therapist used the ABC model and continuum concept. This attempt was not successful since Jasmine rarely understood the message being conveyed. The therapist chose to use the example of temperature to create a better understanding in Jasmine. He explained the continuum concept using temperature. The therapist then used a plain paper sheet with a cube drawn on it. He raised it up and asked Jasmine to say what she observed. Jasmine realized that the diagram was in three dimensions. As Jasmine was making the observation, the therapist also applied normalization after considering her level of understanding. It was remarkable that Jasmine had gained self-confidence and stable mood though she reserved the belief that the voices were from external sources. Jasmine went through 22 sessions of the therapy, and the disturbing voices had turned into gentle conversations that reminded her of the cup of coffee she always had with friends before the bomb blast incidence.
There are some specific CBT interventions that can be used in the treatment of certain symptoms. It is important to note that the possibility or degrees of recurring symptoms are different depending on the patient. Through a training program, patients can be educated on how to live a productive and social life. A successful treatment of schizophrenia does not involve only one treatment termed as the best. There are several treatments applied alongside support programs to aid quick recovery of the patients. Some of these treatments include; use of antipsychotic medication, psychiatric rehabilitation and training on social skills (Yoshinaga, 2017). The effect of antipsychotic drugs is not in the cure of schizophrenia rather it reduces the intensity of symptoms. By reducing the intensity of symptoms, the appearance of the patient is improved, and he/she can go on with daily activities as normal.
Another benefit of using the psychotic drugs is that symptoms like poor concentration are reduced. It is important also to note that medications are not a lasting solution since they only help in the first step.
Community support programs offer psychiatric rehabilitation to patients which instill instrumental and personal skills amid environmental support. These skills are necessary since they help an individual to fit in all kinds of environment. According to research, most people often develop schizophrenia during their career-performing years, the ages of 18 years to 36 years. This makes those who have the mental illness to have emotional problems, thinking difficulty and poor performance at work (Happell, 2013). Through psychiatric rehabilitation social skills training, this offers the solution to a better life. A program that involves social skill training equips the patient on the way to manage symptoms and live an independent life. The process of managing symptoms involves identification of warning signals, controlling symptoms that are ceaseless and prevention of possible causes of stress.
In a bid to explain the cultural and other psychosocial aspects, we are going to consider the case study of China. Studies show that Chinese show less concern for health services related to mental health. A CBT model was modified to match the culture and behavior of clients in China. There are several personal and cultural expectations from the clients in China. These expectations from CBT were separately classified. Some of the expectations from clients include; a therapist who is authoritative, reduced ambiguity tolerance, brief therapy for large amounts of money and instant problem resolving (Lin, 2017). On the other hand, the cultural expectations included; use of Chinese medications, fast change into the mainstream culture and humility in the therapy process.
Conclusion
There are tireless efforts to use different interventions for the benefit of patients who suffer from mental illnesses by mental health nurses. A major intervention is in use of CBT (Cognitive Behavioural Therapy) which has proved to be an effective method for clinical application. For this therapy process to be realistic, it must be regarded to be of relevance to nurses and the general public.
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