Cognitive Behavioral Therapy in Advanced Practice

Nursing: An Overview
Abstract

Advanced practice nurses (APNs) act as coach, mentor, and guide in order to provide
necessary education, counseling, and skills training for individuals they treat. In counseling
and therapy interactions, the approaches become more complicated as psychiatric medication,
physical complications, and psychological conditions interplay. The end result is that APNs are
requesting specialized, empirically tested evidence to guide their practices. Cognitive
behavioral therapy (CBT) meets the scientific standard for effective techniques and
interventions that are empirically based. Therefore, CBT is the ideal vehicle for the APN to
guide counseling and education interactions with individuals. This paper presents a broad
overview of cognitive behavioral interventions that can be used in any setting of APN practice.

Introduction to Cognitive Behavioral Therapy

CBT is a psychotherapeutic model that includes a process of engaging an individual in a

collaborative manner in order to examine the way the individual constructs and
understands the world around him or her (cognitions). The cognitive behavioral therapist
evaluates processes by which the individual acts on those cognitions (behaviors). The targeted
behaviors and cognitions are challenged through a series of behavioral or cognitive
experiments aimed to gradually change one's way of thinking, behaving, and interacting within
the environment.

The therapist uses a process of guided discovery to help the individual uncover
belief systems or conclusions that are unconsciously influencing current
feelings, behaviors, or thoughts. Overview of Cognitive Behavioral Therapy

CBT is based on treatment plans that are clearly conceptualized and based on tested theories
that guide the clinician through each action, session, and overall plan of care. It is the most
widely researched psychotherapeutic model with demonstrated effectiveness in the treatment
of a wide range of emotional and behavioral problems.[3-9]

Efficacy of Cognitive Behavioral Therapy

Cognitive therapy and, by extension, CBT have demonstrated empirical efficacy in a wide
range of medical disorders such as tinnitus,[10] chronic pain disorders,[11-16] premenstrual
dysphoric disorder,[17,18] sexual disorders,[18] and sleep disturbances.[19] In addition, CBT has
been proven to have superior efficacy as a psychotherapeutic method for mood disorders such
as depression,[5,20-22] anxiety, and panic disorders.[23-31]

CBT, as opposed to other psychotherapeutic models, has proven efficacy for disorders such as
eating disorders,[32-34] personality disorders,[6] substance misuse disorders,[35,36] marital
problems,[37-39] posttraumatic stress disorder,[9,40-42]self-injurious behaviors,[35] obsessive
compulsive disorder,[7,43-46] schizophrenic symptom reduction,[47-49] hypochondriasis[50] and
somatoform disorder, antisocial behaviors,[51] and sexual offense spectrum disorders.[52]
Guiding Principles of Cognitive Behavioral Therapy

Cognitive Set. Each individual responds in an idiosyncratic manner to their environment.

Each situation encountered requires the individual to process incoming data, analyze the
content and meaning, and then respond in a way that makes sense to that person. The
interpretation of the data and meaning assigned to it results in that person's emotional
reaction to the situation and behavioral response based upon the interpretation and emotion.

CBT posits that thoughts, behaviors, and feelings interact to form a cognitive "set." If there are
adaptations or changes to one area of the "set," the remaining components will also become
altered. The therapist and the individual investigate the "set," determine if change is
warranted, and establish outcome goals that are reasonable, attainable, and measurable.

The therapist's role is to act as a coach, mentor, or guide through the process; to provide
necessary skill training; and to help design, in collaboration with the patient, appropriate
experiments with high likelihood for success.[1] The therapist uses techniques that include
collaborative empiricism and guided discovery (Socratic method of questioning) to assist the
individual in challenging mistaken assumptions and other cognitive errors that may be
affecting that person's response to a given situation.[1]

Cognitive Shift. If an individual is under duress, as in anxiety or depressive states, that

person's unique coding system becomes more primitive or reactionary, resulting in a skewing
of the information processing. The result of this skewing is a "cognitive shift" that introduces
bias into the interpretations, inferences, and coding mechanisms, resulting in distorted
thoughts or cognitions.[53]

The process of skewing based on the individual's coding system results in a pattern of unique
idiosyncratic vulnerabilities that predispose one to psychological distress.[1] Epictetus said
thousands of years ago that "everyone must deal with each thing according to the view which
he forms about it."[54] The idiosyncratic view is a manifestation of individual cognitive
processing patterns.

Development of Cognitive Behavioral Therapy

Cognitive therapy differs significantly from other models of psychotherapy in that it "is a
collaborative process of empirical investigation, reality testing, and problem solving between
the therapist and the patient."[55] It is generally agreed that CBT evolved primarily from the
work of Aaron T. Beck, who conducted systematic studies on depression and suicidal thinking
using structured cognitive therapy with clear guidelines to follow and specific procedures.[56]

During the 1970s, researchers began to apply behavioral techniques to cognitive theories and
strategies. Prior to this, traditional behavioral experiments were used to shape measurable
behaviors, with little attention paid to the cognitive processes involved in the behavioral and
emotional changes. Fearful responses were extinguished with exposure protocols, for example.

With the addition of cognitive therapy to behavioral experimentation, extensive research has
demonstrated significant efficacy in the combined approach, using cognitive techniques (to
modify fearful cognitions, for example) along with behavioral techniques (such as exposure
therapy and relaxation training). It is imperative that interventions target all 3 foci (cognition,
behavior, and emotion) in order to effect sustainable changes, cognition being the pivotal
point.

Cognitive Behavioral Therapy Techniques and Targets

CBT is based on the assumption that each individual behaves, thinks, and feels about a certain
situation based upon their interpretation of that situation. CBT uses specific techniques to help
people learn to recognize the way that their thoughts, feelings, and subsequent behaviors
interact.

Table 1 and Table 2 provide an overview of some of the most commonly used CBT techniques.
The techniques are chosen based upon the target feeling or behavior. In order to begin the
change process in the CBT approach, the therapist works with the individual to uncover their
unique automatic thoughts.

Table 1. Cognitive Techniques

Cognitive
Technique Description
Downward Arrow The individual is helped to uncover underlying assumptions in logic and
sequence through careful questioning by the therapist, who asks, "If this is
true, then what happens?"
Idiosyncratic The therapist assists the client to clarify statements and terms used so that
Meaning both the therapist and the patient have a clear understanding of perceived
reality.
Labeling of The individual is helped to identify automatic thoughts that are
Distortions "dysfunctional or irrational." For example, the therapist might stop the
individual during the session and have them repeat a portion of their
sentence, saying, "did you mean you were 'starving to death' or you were
really hungry?" to help the person evaluate internal dialogue and the
images they evoke as a way to help them self-monitor for more accurate
description.
Questioning the The individual is helped to question the facts related to their cognitions and
Evidence conclusions. This procedure investigates whether information is based on
facts or assumptions.
Examining Options This technique involves the development of all possible alternative
and Alternatives explanations in order to learn the skills in generating options rather than
"only one way" thinking.
Reattribution In individuals with the habit of accepting all or most of the blame for
outcomes, this is an excellent technique for redistribution of responsibility.
This is also helpful for individuals with personality disorders that place the
blame squarely on the shoulders of others for most outcomes.
Decatastrophizing Catastrophic thinking is one of the hallmarks of anxious individuals. These
individuals tend to focus on the most negative possible outcome of any
given situation. Decatastrophizing allows for balance and realistic focusing
by examining the "worst possible outcome" and developing a plan of
action.
Advantages and For individuals who appear to be stuck between 2 options, examination of
Disadvantages the advantages and disadvantages of certain situations helps them to
 develop alternative perspectives. This breaks the "all-or-nothing" mindset
and permits a more balanced view of the situation.
Paradox or This type of technique should only be used by the very skilled therapist;
Exaggeration otherwise, the patient may view this technique as sarcasm or belittling.
When used appropriately, the therapist takes an issue to the extreme to
help the person see the absurdity of their sometimes overinflated
viewpoints.
Turning Adversity This technique is akin to "making lemonade out of lemons." The individual
to Advantage is helped to identify how they can use what appears to be a negative
situation to their advantage. For example, being turned down for a job may
open the individual up for more attractive possibilities that they had not
investigated.
Cognitive Prior to making a behavioral change, it is sometimes less threatening to
Rehearsal "practice" the new behavior through visualization and discussion. For
example, this would include practicing assertiveness in a mirror or "talking
through" a confrontation out loud prior to actually following through with
the conversation.
Automatic Thought The automatic thought record (ATR) is a key component of CBT. The ATR is
Records used as homework after introducing the process within the therapy session.
The individual completes the columns identifying a troubling situation,
resulting emotion, and thoughts associated with both. The therapist and
patient work on clarification and development of "rational" responses in
order to debate or challenge the original reaction.

Table 2. Behavioral Techniques

Behavioral
Technique Description
Assertiveness Assertiveness training involves a combination of cognitive and behavioral
Training practice. The therapist may model assertive behavior, assist the patient within
the session with role-play, and finally develop in vivo experiments that
increase in complexity over time until the new behavior is internalized.
Behavioral The behavioral component usually follows the cognitive training component
Rehearsal and again includes behavioral experiments to gather more evidence or to
develop more effective responses and styles.
Graded Task This technique is used in a series of steps that become increasingly more
Assignments complex or difficult as a means of overcoming fears or anxiety-producing
threats.

Bibliotherapy: The cognitive behavioral therapist will often prescribe specific

readings related to the individual's difficulties.
Guided Therapists often employ behavioral techniques aimed at reduction of
Relaxation and autonomic nervous system responses to anxiety such as measured breathing,
Meditation relaxation training, meditation, and other techniques.
Social Skills These skills are often taken for granted by many individuals. It is important for
Training the therapist to review and instruct on behaviors that will improve the potential
for successful social interactions.
Shame- This technique was first introduced by Albert Ellis as a rational emotive therapy
Attacking technique. Rational emotive therapists have the patient engage in behavioral
Exercises experiments that emphasize their concern for what others think of them. The
individual develops an experiment testing their hypothesis (people think I smile
funny when I walk and look at me weird) and collects data between sessions.
 (Have a neutral observer collect the actual data. This helps them differentiate
between "feeling" and "fact" to move past shame-based behaviors [see
homework below].
Homework The hallmark behavioral technique in CBT is the use of homework assignments.
Activities are designed within the therapy session to be carried outside and
practiced between sessions.

Automatic Thoughts

Dysfunctional or maladaptive thoughts are perceived by the individual as "automatic," with

little personal control over the cognition. In fact, these automatic thoughts (ATs) are the target
for CBT techniques. Dysfunctional ATs are upsetting or not helpful to an individual and usually
contain distorted conclusions or premises. This is what makes cognitive distortions excellent
targets for change: the individual is trained to evaluate the distorted thought pattern and alter
it in a more adaptive fashion.

The therapist often focuses on the most common type of distortion that an individual uses,
points out the process to the individual, and then assists him or her in exploring the factual
basis of the cognitive style. See Table 3 for examples of cognitive distortions.

Table 3. Examples of Cognitive Distortions

Cognitive Distortion Example

All-or-nothing (dichotomous thinking) He either loves me or he doesn't.
Mind reading (this is not thought I am sure they all think I am stupid.
insertion which is psychotic and in the
opposite direction)
Emotional reasoning I feel that way — therefore that is the way it is.
Personalization I'm sure that comment was directed at me.
Global labeling/globalization Everything I do turns out awful!
Disqualifying the positive I know it turned out okay, but it was just a coincidence.
(a variant of yes-but thinking)
"Should" statements I really should help her even though I don't want to. I
"should" do my homework (take a bath, go to work,
get a job, smile, say hello....)
Comparing Everyone else seems to be able to do this — why can't
I?
Perfectionism Anything worth doing is worth doing well.
Ostrich technique If I ignore it, it will go away. Someday he will stop
yelling at me. Someday she will be nice to me.
Someday I will get a good job and a nice house and
and and...
Filtering I don't care if he does all of those nice things for me,
he didn't call this morning so I know he hates me!
Modifications or Alternative Approaches Within Cognitive Behavioral Therapy

Schema Therapy

Dr. Jeffrey Young developed schema therapy (ST) as an expansion, extension, and revision of
classic CBT.[57] Young stated that, "in comparison with standard cognitive therapy, ST probes
more deeply into the childhood origins of distorted thinking, relies more on imagery and
emotion-focused techniques."[58] Individuals are guided by belief systems, or schema,
generated by every experience, action, reaction, and interaction and based on our own
personal, religious, familial, cultural, gender, and age-related contacts that we have had over
the years.[1,2,53,59]

Fundamental core beliefs or assumptions are a unique component of the perceptual filter
people use to view their world. Cognitive behavioral therapists seek to change schemas that
are no longer useful or are maladaptive. Schemas may be selected by an individual for recall,
suppressed in memory, or they may be used for interpretation of information, generation of
affect, motivation, or action and/or control.[1,2] ST is, and has been, a critical component of
classical CBT since its inception. Understanding an individual's schemas, belief systems, and
underlying attitudes is essential in understanding the individual.[2]

Schemas are in a constant state of adaptation and become increasingly complex as an

individual ages. Thus, the process of adaptation may serve to help or hinder the individual as
they apply their schema to new situations. Young proposed that early schemas are more
resistant to change than schemas that develop later in life.[60] He identified these schemas
as early maladaptive schema.

Young identified 5 domains that correspond with the basic needs in children. The domains
are: disconnection and rejection, impaired autonomy and performance, impaired limits, other-
directedness, and overvigilance and inhibition. [57] When one's needs are not met, early
maladaptive schema develops, which is explored and modified in ST treatment.

Young further postulated that there are 3 processes regulating the functioning of activated
schema. These processes are schema maintenance, schema avoidance, and schema
compensation.[57] Basically, these coping styles or processes correspond with the basic stance
an individual takes when a schema is triggered: surrender to it (maintenance), avoid it, or fight
back (compensation).[57] For additional information on ST, refer to Dr. Young's Web site:
http://www.schematherapy.com.[61]

Rational Emotive Behavior Therapy

Rational emotive behavioral therapy (REBT) began as rational therapy (RT) in the early 1950s
and was based on the combined principles of Greek and Roman stoicism.[62] The name was
changed, first to include emotional and later behavioral components, even though Ellis had
always incorporated both of these techniques into RT.

REBT is a form of CBT and is practiced by therapists around the world.[63] The model is based
on the premise that all humans learn both self-preserving and self-destructive thoughts,
feelings, and behaviors.[63] Illogical behaviors and thoughts are considered self-defeating while
logical, flexible, and empirically validated thinking generates self-enhancing emotion.[63]

The basis of REBT is to teach individuals strategies to control dysfunctional emotions using an
"ABC" model with a structured format.[62] The individual is educated on the relationship
between their B (beliefs) and C (emotional/behavioral consequences) and the A (activating
events). Therapy is directed at: (1) acknowledging that emotions/behaviors are dysfunctional;
(2) identifying irrational beliefs; (3) recognizing that these beliefs are illogical and maladaptive;
and (4) replacing the irrational beliefs with ones that are logical and adaptive.[63]

Dialectical Behavioral Therapy

Another approach to CBT is dialectical behavior therapy (DBT), which was developed by Dr.
Marsha Linehan in her work with parasuicidal patients.[64] Significant empirical support has
been shown for the efficacy of treatment with DBT in parasuicidal individuals with cluster B
personality disorders.[65] This treatment is a combination of behavior therapy and acceptance
approaches blended together by a set biosocial theory and multiple modes of treatment (eg,
individual therapy, group skills training, pharmacotherapy).

Mindfulness skills target improvements in awareness of internal experiences without judgment.

Mindfulness is the cognitive therapy technique that is otherwise known as, "OK, tell me what
you are thinking/feeling right here, right now." Emotion regulation skills are designed to reduce
vulnerability to emotions, increase positive emotions, accept emotions, and change specific
emotional states using behavioral and cognitive skills. Distress tolerance skills assist patients
in tolerating ordinary life pain without engaging in behavior that is self punishing.[63-65]

Case Example: Treatment of Depression With CBT

Kathy is a 42-year-old married woman who has been diagnosed with breast cancer. Kathy has
completed 1 series of chemotherapy treatments following a mastectomy with reconstruction.
Kathy makes an appointment with her nurse practitioner, Karen, for evaluation of depression.
She is reporting difficulty falling asleep, early morning awakening at 4:00 am, tearfulness,
anergia, low motivation, hopelessness, and helplessness.

Kathy also has negative views of herself ("I am so ugly now") and her future ("I don't believe I
will ever have a normal life again"). Karen evaluates her for medical explanations for her
symptoms such as anemia, which is common in individuals treated with chemotherapy, and
finds that all serum levels are normal. Karen decides to call Kathy in for an appointment to talk
about her symptoms and options for therapy.

Karen structures her session with Kathy in the following way:

1. Assess Kathy's mood and review her view of recent events.

2. Collaboratively set an agenda for the meeting, making sure that discussion of
psychotherapy and medication options are a component.

3. Review results of Kathy's medical evaluation.

 4. Discuss Kathy's issues and views as identified on the agenda.

5. Introduce or review specific skills to address her cognitions and behaviors.

6. Formulate a homework task and identify any factors that may interfere with homework
completion.

7. Help Kathy summarize the main points of today's meeting and conclusion.

8. Discuss her thoughts and feelings about the session.

Karen uses a Socratic dialogue technique to talk with Kathy. The goal of her questions is to
understand the meaning Kathy is attaching to her experiences and the way she understands
herself as an individual. Karen does this by gently and persistently evaluating experiences and
Kathy's interpretations that support her beliefs and attitudes as well as examining the
advantages and disadvantages of maintaining those views.

Specific questions Karen might ask include:

• What are the activities that you have enjoyed in the past?

• What activities give you a sense of pleasure?

• Is it possible to engage in (name of activity) part of the time, or to a smaller degree?

• What might be the consequence of engaging in (name of activity) to this degree?

• How can you start engaging in this activity?

Examining Kathy's thoughts and allowing her to develop an alternative plan gives her control
over her behavioral choices. This increases the possibility that Kathy will "own" the plan and
act upon it in between sessions. Karen and Kathy evaluate progress on the plan (homework) in
the following session. Depending upon the results of the homework, Karen and Kathy will
modify the plan or move on to the next issue.

Karen uses this same method of questioning to evaluate Kathy's negative thought processes
and faulty conclusions.

Karen: "You said that your life will never be normal again. What do you mean by
normal?" (evaluating idiosyncratic meaning)

Kathy: "I am so deformed and I don't have any energy and I don't care about anything
anymore!"

Karen: "Which is more troubling to you — feeling deformed, no energy, or not caring about
anything?" (Note: Karen is helping Kathy focus on one problem/issue at a time, making change
more reasonable than a "scattergun" approach).

Kathy: "If I have to choose, I would say feeling deformed."

Karen: "Okay. Let's start with that feeling. Tell me more about feeling deformed."

Kathy: "My right breast is rebuilt — but I don't have a nipple and I have this huge scar across
my chest! It is so ugly!"

Karen: "What choices have you discussed with your surgeon about replacing your
nipple?" (Examining alternatives)

Kathy: "He said there were more surgeries I could have to build one, or I could have a tattoo of
a nipple put on it."

Karen: "Which of these options is more appealing to you?" (Note: Karen did not ask if one
option was more appealing. She is giving Kathy limited choices in a positive direction.)

Kathy: "I think a tattoo — the other surgery really sounds painful."

Karen: "Would the tattoo make you feel more or less deformed?" (Note: the answer seems
obvious; however, it is important for Kathy to move from an all-or-nothing mindset to one that
includes a spectrum of possibilities.)

Karen: "What have you investigated about this possibility?"

Kathy: "I haven't started that yet."

Karen: "Where will you start investigating this possibility?" (Note: Karen does not ask a
question that allows for a nonstart reply.) (homework)

Kathy: "Well, my daughter got a tattoo last month — I can ask her where she went. She is
going to laugh when I ask her about a tattoo parlor!" (Kathy is now smiling and even laughing,
which indicates forward movement and a shift from negative to positive mindset.)

Karen: "You'll have to let me know how that goes!" (Note: Again, Karen states her response in
the affirmative expectationthat Kathy will follow through as opposed to asking her if she will
ask her daughter, which would allow for a negative response.)

Then end result of the session with Kathy is that Kathy now has a homework assignment that
will shift her image of "deformed" toward a more positive possibility.

Conclusion

CBT is a process of engaging an individual in a collaborative manner in order to examine the

way the individual constructs and understands the world around them (cognitions), and to
evaluate the processes by which the individual acts on those cognitions (behaviors). The role
of the APN is to act as a coach, mentor, or guide through the process, provide the necessary
skills training, and design appropriate experiments with high likelihood for success in
collaboration with the patient.

There has been a rapid increase in the numbers of psychiatric nurses who obtain advanced
degrees and develop independent practices. The APN specializes in holistic assessment,
prevention, and treatment approaches in a variety of settings. The approaches become more
complicated as psychiatric medication, physical complications, and psychological conditions
collide.

APNs need specialized and empirically tested evidence to guide their practices. CBT has been
proven to integrate well in nursing practice and meets the scientific standard for effective
techniques and interventions that are empirically based. As a result, CBT is the ideal vehicle
for the APN to use to guide counseling and education interactions with individuals.

Once the belief systems, called schema, are uncovered, the therapist helps the patient to
experiment with alternative explanations and responses in order to evaluate the evidence of
this faulty reasoning.

Advanced practice psychiatric nurses (APPNs) are in a unique position to coordinate physical,
psychiatric, and social theory into true holistic care for the individual using the highest
standards of empirically supported treatment. Given the evidence supporting CBT, it makes
sense that APPNs become adept in the use of this psychotherapeutic method.

Reference:
http://www.medscape.com/viewarticle/545336_3

Studying the field of psychiatry as aspect in nursing Is really enjoyable for me

because we get to know different mental illnesses that arises nowadays, and how to treat
such. One of the widely used therapy to treat mental illnesses and disorders is the
Cognitive- Behavioral Therapy where in it is very helpful in treating not only anxiety
disorders which is the highest prevalence in all mental disorders but also an effective
treatment for variety of problems, including mood, anxiety, personality, eating, substance
abuse, and psychotic disorders by emphasizing the important role of thinking in how we
feel and what we do.

In order for the therapy to sound effective, therapeutic relationship is necessary.

This therapy assumes that the main reason people get better in therapy is because of the
positive relationship between the therapist and client. Cognitive-behavioral therapists
believe it is important to have a good, trusting relationship, but that is not enough. CBT
therapists believe that the clients change because they learn how to think differently and
they act on that learning. Therefore, CBT therapists focus on teaching rational self-
counseling skills. We also have many advantages if we use this kind of therapy to our
clients; it is briefer, because it’s highly instructive nature and the fact that it makes use of
homework assignments. It is also time limited in that we help clients understand at the
very beginning of the therapy process that there will be a point when the formal therapy
will end. The ending of the formal therapy is a decision made by the therapist and
client. Therefore, CBT is not an open-ended, never-ending process. CBT focuses on the
client's goals. We do not tell our clients what their goals "should" be, or what they
"should" tolerate. We are also directive in the sense that we show our clients how to
think and behave in ways to obtain what they want. Therefore, CBT therapists do not tell
their clients what to do -- rather, they teach their clients how to do.

Most importantly, Cognitive-behavioral therapists seek to learn what their clients

want out of life (their goals) and then help their clients achieve those goals. And our
roles as nurse and is to listen, teach, and encourage, while the client's roles is to express
concerns, learn, and implement that learning.