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Journal of Psychiatric and Mental Health Nursing, 2000, 7, 343–354

The strengths and weaknesses of cognitive behavioural


approaches to treating depression and their potential for
wider utilization by mental health nurses
B. F. BEECH rmn bsc (hons) ma cert ed (fe)
Lecturer, Department of Nursing and Midwifery, Keele University, Staffordshire, UK

Correspondence: BEECH B. F. (2000) Journal of Psychiatric and Mental Health Nursing 7, 343–354
B. F. Beech The strengths and weaknesses of cognitive behavioural approaches to treating
Department of Nursing and depression and their potential for wider utilization by mental health nurses
Midwifery,
59 The Covert
Depression is widely acknowledged to be the major factor implicated with suicide, an enor-
Keele University
mous financial cost on the economies of western countries and a source of intense despair
Stafford-shire
for millions of people around the world. A steady stream of articles are published both in
ST5 5BG
popular, generic and specialist nursing journals that illustrate the potential of cognitive
UK
behavioural therapies in the treatment of depression. Should these therapies be restricted
for use by registered therapists or do the techniques have a wider application? The mar-
keting of these approaches for use by nurses prompted a review of the purported strengths
and weaknesses of these approaches in comparison with other possible alternatives. Many
mental health nurses in community settings already use cognitive behavioural approaches
with clients. Here it will be argued that several of the recognized strengths of cognitive
behavioural approaches lend themselves to incorporation in nurse–patient interactions
in varied in-patient settings by nurses who spend protracted periods of time with de-
pressed patients but lack formal therapist qualifications and do not consider themselves
counsellors.

Keywords: behavioural, cognitive, depression, mental health nurses, strengths, weaknesses

Accepted for publication: 1 March 2000

attack on other therapeutic approaches. Understandably,


Introduction
the material presented will not be as comprehensive as a
Both in mainstream generic and specialist nursing journals Cochrane-style systematic review.
a steady flow of articles continue to be published that Knowledge about the relative strengths and weak-
report on cognitive-behavioural therapy (CBT) or cogni- nesses of different therapeutic approaches is considered
tive therapy (CT) – the titles are considered equivalent in to be essential when approaches are less than 100%
this article – and its utility by nurses in the treatment of successful with clients. It is apparent that the treatment
depression. Recently reported single case studies and tech- of mental health problems in general and depression in
nical reviews include those by Stewart (1994), Garland particular is not always successful (Gournay 1997).
(1996), Perez (1996), Sourial (1997), Barker (1998) and This knowledge can drive the allocation of resources to
Garland (1998). client groups or individual client problems and indicate
Given this degree of advocacy it would seem reason- appropriate clinical personnel. A consideration of this
able to review the available literature on the purported type is also aligned with the emphasis on evidence-
strengths and weaknesses of CBT, although it is not the based practice that is now developing in mental health
intention of the author to indulge in a ‘holier than thou’ services.

© 2000 Blackwell Science Ltd 343


B. F. Beech

In this article it is intended to consider the following General Practitioners, Social Workers or Counsellors
series of contentions: (Gilbert 1992). These figures translate as 1.5–5 million
• Depression is a major mental illness that places great people in the UK suffering severe depression each year. In
demands on primary and specialist care services. addition, many depressed people will not seek assistance
• Cognitive therapy [or cognitive behavioural therapy] and, of those that do consult, the disorder may not be
delivered by cognitive therapists is an effective treat- recognized in many cases.
ment for depression. Gilbert (1992, p. 3) states that estimates suggest that ‘as
• There are only a small number of registered cognitive many as 1 in 4 or 5 will have an episode of serious depres-
therapists in the UK (minute in comparison with the sion warranting treatment at some point in their lives’ and
scale of the problem). cites a figure of 100 million depressed people worldwide.
• Nurse therapists, psychologists and many mental Depression is recognized as the major factor implicated
health nurses working in day hospital and community in suicide (DoH 1992). Hammen (1997) suggests that
settings successfully use cognitive behavioural appro- diagnosable depressive disorders are implicated in up to
aches with clients on their case-loads. 60% of suicides and adds that 10–15% of individuals
• Many other mental health nurses have multiple pro- with major depressive disorder eventually kill themselves.
tracted interactions each day, both formal and infor- During 1991, depression is estimated to have cost $29
mal, in varied settings, with patients suffering from billion in the United States in absenteeism, suicides and
depression treatment costs (Abraham et al. 1991), and it is also a
• Cognitive behavioural approaches to depression source of intense despair to millions of people around the
(aspects or components of cognitive therapy) can be world.
competently and effectively utilized by mental health
nurses working in varied hospital and community-
Mental Health Nurses
based NHS settings.
Before these ideas are developed further it is firstly Mental health nurses are present in most, if not all, mental
intended to provide a little more background on depres- health environments in the UK and, indeed, in most of
sion, mental health nursing and cognitive behavioural these settings, have the largest professional presence. Addi-
therapy and then review the purported strengths of cogni- tionally, they would be distinguished from colleagues by
tive behavioural approaches to depression. The disparate having a continuous 24 h presence in institutional settings
findings and assertions of authoritative writers and re- – for example, in acute admission, rehabilitation and
searchers on CBT are reported in a way that allows readers elderly assessment wards, and some community mental
to consolidate their understanding of the potential for health centres.
using cognitive therapies in the treatment of depression. Many mental health nurses working in community
mental health or primary care teams and settings have
gained some appropriate training and expertise and use
Background
cognitive behavioural approaches with clients on their
caseloads. This article will attempt to underpin and legiti-
Depression
mate the reality of clinical work for these nurses.
Depression is frequently referred to as ‘the common cold Moreover, in institutional settings, inpatients who are
of psychopathology’ (Williams 1989, Calarco & Krone diagnosed as suffering from depression will have frequent
1991) and this phrase accurately suggests its prevalence but or continuous contact with nursing staff detailed in their
seriously under-states many of its other characteristics and care plans as part of observation policies, if for no other
effects. Depending on the definition of depression adopted, reason (Reid & Long 1993, Duffy 1995, Moore et al.
it is frequently reported that 1 in 1000 of the general 1995, Fletcher 1999). Hence, it could be argued that many
population will be hospitalized with depression each year, opportunities exist for a large proportion of the work force
whilst a further 2 in 1000 will be referred to a psychiatrist to interact therapeutically, in both individual and group
as outpatients (Paykel 1989, Gilbert 1992). The pos- contexts, with a major client group that place heavy
sible effects of recent hospital closures and transition to demands on the psychiatric services.
community-based care on these figures are not known. Whilst staff will talk to and interact with clients, the style
The prevalence rate of serious depression in the general of interaction ranges from unhelpful/destructive/con-
population is about 5% although estimates vary widely trolling actions (sitting outside, sitting in silence, ‘backing
(Paykel 1989). In the UK each year, between 3 and 10% off’; Fletcher 1999) through neutral ‘chit-chat’ (‘passing of
of the population will seek treatment from other sources, time’; Duffy 1995) to helpful/therapeutic dialogue and

344 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches

activity (Reid & Long 1993). A recent publication en- terize the range of therapies grouped under the CBT
titled ‘Acute Problems’ found a ‘care vacuum’ on acute heading. Nevertheless the range of cognitive behavioural
psychiatric wards for 30% of patients who engaged in no approaches are widely acknowledged as sharing some
activity, therapeutic or recreational, during their stay common characteristics as specified in Fig. 1 (Newell &
(Sainsbury Centre for Mental Health 1998). Dryden 1991).
Most of these nursing staff currently do not possess, and Clark & Beck (1990) summarize the differences between
probably will never obtain, any recognized specialist approaches in terms of primary cognitive construct tar-
therapist qualifications, since the system currently values geted, methods used to achieve change, range of applica-
other skills more highly (e.g. maintenance of safe environ- tions, and extent to which practice is derived from a
ments, administration and management of medication). A distinct cognitive model of psychopathology.
clear, uncomplicated framework is needed on which to Twaddle & Scott (1991) list four models of depression,
base therapeutic activity and, in so doing, maximize the these being the works of Beck (1976), Ellis (1970), Rehm
benefits of the undoubtedly numerous opportunities that (1977) and Seligman (1981). In the same text, Newell &
arise. Later it will be argued that, given certain aspects Dryden (1991, p. 5) cite Rachman & Wilson’s (1980) iden-
of the review of cognitive behavioural therapies, large tification of ‘three major schools of thought in cognitive
numbers of mental health nurses, including many working therapy’, these being Ellis’s Rational Emotive Therapy
in institutional settings, whilst not being registered as ther- (RET), Beck’s Cognitive Therapy (CT) and Meichenbaum’s
apists, are nevertheless well placed to use straightforward (1969) Self Instructional Therapy (SIT). Calarco & Krone
cognitive behavioural techniques to enhance and structure (1991, p. 575) refer to the models of Beck and Seligman
their interactions with clients. In this way the balance as ‘the most dominant cognitive therapies related to
between unhelpful, neutral, and helpful interactions could depression’.
be dramatically shifted in the therapeutic direction. According to its own publicity material, the British Asso-
ciation for Behavioural and Cognitive Psychotherapies
(BABCP), a multidisciplinary interest group for people
Cognitive Behavioural Therapy and Cognitive
involved in the practice and theory of behavioural and
Behavioural Therapists
cognitive psychotherapy, currently has 3000 members.
Emery & Tracy (1987, p. 3) define CBT as ‘a series of These consist of clinical psychologists, psychiatrists, social
strategies that relieve psychological suffering by correcting workers, nurses, counsellors, GPs, researchers, academics
distorted and maladaptive thinking. The therapy is based and colleagues. However, only a subset [N = 363] of
on a theory of psychopathology that recognizes the recip- these people are currently accredited by the BABCP and
rocal interrelationship among the cognitive, behavioural, registered as cognitive/behavioural therapists with the
somatic and emotional systems.’ United Kingdom Council for Psychotherapy (UKCP) (from
An immediate initial challenge in attempting to collate personal inquiry to UKCP).
material is to manage the diversity of theoretical models In the UK, nurse behaviour therapists will obviously
and subtle differences in clinical emphasis that charac- utilize cognitive behavioural therapy techniques. A 1992

Figure 1
Commonalties between models (Newell &
Dryden 1991)

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354 345
B. F. Beech

survey of almost 150 nurse therapists (the entire output ticularly effective for more severely depressed patients. No
of four training centres who were still resident in the UK such differences were observed for less severely depressed
and practising as nurses) showed clients with depression patients but there was a hint that psychotherapy may do
formed a part of the caseload (mean 10%) and cognitive better in the longer term. In reviewing the relapse figures
therapy to be the second most frequent technique used for the study, Elkin (1994) suggests the possibility that
(Newell & Gournay 1994). Less clear was the level of short-term treatment of depression has been ‘oversold‘,
preparation and training in the use of these techniques. The whatever the treatment, and advises that longer periods of
latest survey, which follows up all nurse therapists to 1998, initial treatment, maintenance treatments, ‘booster ses-
clearly shows the continued expansion of nurse therapists sions’ and integrated approaches be investigated. Analyses
into this cognitive therapy area and the rise of depression of the findings of this hugely significant study continue
to the top of the list of reasons for referral (Professor to be published (Blatt et al. 1996, Agosti & Ocepek-
K. Gournay, personal communication). It is also estimated Welikson 1997).
that, on average, patients with depression could make Hollon & Beck (1994, p. 432) conclude that evidence
up 20 of the 70 patients treated to completion each from most studies (with the exception of the NIMH study)
year by nurse therapists (Professor K. Gournay, personal indicates that cognitive therapy is ‘about as effective as
communication). pharmacotherapy regardless of severity, at least among
Cognitive behavioural approaches are widely admin- nonpsychotic patients’.
istered by psychologists, psychiatrists and other pro- Furthermore, its use is not contra-indicated by the pre-
fessionals. A recent estimate suggests that approximately scription of medication and, indeed, the two treatments
one-quarter to one-third of the 3000 clinical psychologists applied simultaneously may have a reinforcing effect
chartered by the British Psychological Society would be (Evans et al. 1992). Readers are referred to Bergin &
suitably skilled to provided cognitive behavioural inter- Garfield (1994) for a detailed discussion of these and other
ventions (Professor K. Gournay, personal communication). related issues.
Many excellent, technically detailed texts exist, for
example Williams (1992) and Hawton et al. (1989), which
Strengths of a cognitive behavioural approach
allow techniques to be communicated, standardized, repli-
to treatment
cated and evaluated by other therapists (Stewart 1994).
The approach adopted in the following review is to assume In comparison with psychoanalysis, which is costly and
that comments apply generally to cognitive behavioural time-consuming, cognitive behavioural approaches are
approaches unless they are specifically attributed to a shorter in duration and emphasize symptom management
particular approach. (compensation) rather than insight (Abraham et al. 1991,
Firstly, whilst there is continuing debate about the accu- Spinelli 1994). A recent study by Scott et al. (1997) showed
racy of aspects of underlying cognitive behavioural theory that brief cognitive therapy for depression in primary care
(Barker 1998), there is general agreement in the clinical (six sessions) may be beneficial whilst Barkham et al.
literature that the techniques of cognitive behavioural (1992) showed the benefits of ‘two plus one’ sessions of
approaches to therapy are likely to be effective in treating cognitive therapy for depression.
depression (Brewin 1996). The National Institute of Involvement of the client is one of the hallmarks of cog-
Mental Health Treatment of Depression Collaborative nitive behavioural approaches. An equal partnership is
Research Program (NIMH TDCRP), a large US multi-site, actively sought in the interpretation of cognitions (unlike
multi-treatment condition study of 250 patients with psychoanalysis; see Abraham et al. 1991) and when engag-
depression treated with defined treatments by selected ing in Socratic dialogue. More generally, the importance of
therapists, has been widely reported (Elkin et al. 1989, good client–therapist interaction is increasingly acknowl-
Shea et al. 1992) and still proves a seminal study. Inter- edged by most cognitive behavioural approaches, but not
pretation is complex and ongoing but Elkin (1994) attests as an end in itself. The CBT literature increasingly empha-
to the comparative effectiveness of CBT in treating depres- sizes the importance of therapeutic alliance as a precondi-
sion and the lack of any significant difference between tion for successful application of cognitive techniques and
cognitive therapy, interpersonal therapy or antidepressant desired patient outcomes (Muran et al. 1995, Blatt et al.
medication at termination of treatment. 1996, Raue et al. 1997).
However, lack of significant difference did not exactly Unlike humanistic approaches, therapist skills are valued
equate to ‘equivalence’. In this study medication was found over particular therapist traits (Newell & Dryden 1991)
to have a more rapid effect with significant differences and, in this regard, Robins & Hayes (1993) conclude
observed at 12 weeks (but not 4 weeks) and also to be par- that cognitive behavioural approaches are associated with

346 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches

symptom reduction beyond the effects due to more general than patients treated to remission with medication, and no
therapy factors (empathy, warmth, etc.). This point is rel- more likely to relapse than patients who were continued
evant to any possible utilization by community psychiatric on medication for the first year of the 2 years follow-up.
nurses (CPNs). It has been demonstrated that, in samples Blackburn & Moore (1997) showed that maintenance cog-
of clients with high levels of depression, CPNs without cog- nitive therapy had a similar prophylactic effect to mainte-
nitive behavioural training and using a Rogerian approach nance medication over a two-year period.
failed to make any impact (Gournay & Brooking 1994, Cost-effectiveness may be maximized by the use of group
Gournay & Brooking 1995). cognitive therapy for certain conditions (Abraham et al.
Sheldon (1995) reports studies that find cognitive 1992, Stravynski et al. 1994, Wilhelm et al. 1999).
behavioural approaches being described as ‘user-friendly’ Williams (1989, p. 174) makes a second point in rela-
by clients in comparison with other therapies and associ- tion to cost, suggesting that possibly in the future research
ates this with the lower ‘drop-out’ rate reported for this will isolate ‘a package of active ingredients . . . for rela-
approach by Twaddle & Scott (1991). Bemporad (1992) tively mild but fairly chronic depressives’ that can be
and Spinelli (1994) also emphasize the focus on ‘the worked through by clients themselves, their GP or CPN in
present’, avoidance of hypothetical constructs such as ‘the a cost-effective manner. In this vein, Jacobson et al. (1996)
unconscious’, nonutilization of transference and resistance, and Gortner et al. (1998) recently showed that CT was
and instructional rather than transferential quality of the effective, but no more so than its two major components
therapist–client relationship, as strengths over the psycho- – behavioural activation (BA) or BA with automatic
analytic therapies. thought modification – in treating episodes of major
The early presentation of the relatively simple cognitive depression. It was no more effective than its components
behavioural model to the client (Haaga & Davidson 1991) in preventing relapse over a two-year time period, wherein
is viewed by many as a strength in that it avoids the pos- almost half of the clients had suffered a relapse.
sible mystique and pretence of all-knowing expert status Computer-delivered CBT, an interesting development for
associated with some other therapies. If the client is suffi- mild to moderate depression, is reported by Selmi et al.
ciently ‘psychologically minded’ to accept this model and (1990). This impressive study demonstrated that six
can identify strongly with cognitive explanations then they sessions of CBT delivered by a computer over a six-
should respond well (Twaddle & Scott 1991). week period was as effective as a therapist using the
Williams (1989) reports that the approaches work across same cognitive behavioural treatment protocol and that
the range of social classes (unlike psychoanalysis), whilst improvement was maintained over a two-month follow-
Twaddle & Scott (1991) assert that lower intelligence up. Although the therapies were delivered over a relatively
and endogenous depression are not necessarily contra- brief time period ‘improvement was substantial and
indications for referral for therapy. equally durable for both treatment groups’ (Selmi et al.
Whilst cognitive behavioural approaches are not 1990, p. 55). The implication of this finding, if confirmed
generally as directly cost-effective as antidepressant psy- by replication, is potentially revolutionary, although this
chopharmacology, being equally effective, they are of use approach will always run a risk of being dismissed by some
when medication is inappropriate. The strength of cogni- critics as impersonal and mechanistic.
tive behavioural approaches would be apparent when The incorporation and use of published material in,
clients will not accept medication for ideological reasons, between, or instead of, therapy sessions – bibliotherapy –
when it can’t be physically tolerated because of side-effects, is also a cost-effective application to the treatment of
when cardiac toxicity prevents prescription (Williams depression in association with therapist support and guid-
1992) or in tackling ‘drug resistant cognitions’ (Twaddle ance (Stevens 1996). Jamison & Scogin (1995) demon-
& Scott 1991). For example, Moore & Blackburn (1997) strated that minimal contact cognitive bibliotherapy –
provide evidence of CT being at least partially effective reading a self-help treatment book for depression that uses
with outpatients with recurrent major depression who fail cognitive behavioural principles – was an effective treat-
to respond to medication. ment for depression with a general adult population. The
Experimental studies have show cognitive behavioural results were both statistically and clinically significant and
approaches to be superior to antidepressant medication in improvement was maintained at a three-month follow-up.
preventing subsequent relapse (Williams 1989, Robins & The authors suggest that the approach could have educa-
Hayes 1993). Evans et al. (1992), cited by Hollon & Beck tional, preventative and public awareness roles but Dryden
(1994), found that patients treated to remission with cog- (1998) cautions that merely reading material is insufficient.
nitive therapy (with or without combined medication) were Advice from bibliotherapy has to be actively followed and
less likely to relapse following termination of treatment practised if it is to be effective.

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354 347
B. F. Beech

Within the cognitive behavioural approaches, Beck’s objective analysis of effectiveness has been placed in stark
Cognitive Therapy (CT) has certain other recognized contrast to psychoanalysis with its vague goals of treat-
strengths over and above those just identified. It is fre- ment, such as ‘freedom from neurotic inhibition’ and
quently reported as the most widely researched psy- ‘greater contentment’ (Bemporad 1992).
chotherapy over the last 25 years (Twaddle & Scott 1991, The cognitive behavioural approaches are not ‘set’. They
Robins & Hayes 1993), with ‘the most substantial empir- continue to evolve and respond to developments in theory
ical support of all the cognitive behavioural approaches’ and accommodate empirical findings, both from cognitive
(Haaga & Davidson 1991, p. 268). A quantitative review psychology and experimental therapy (Robins & Hayes
of 28 studies of outpatients by Dobson (1989) concluded 1993) and are rightly proud of their scientific foundations
that Beck’s cognitive therapy is more effective than waiting and rigour (Spinelli 1994). Newell & Dryden (1991) are
list controls, pharmacotherapies, behavioural treatments critical of psychoanalysis for its lack of empirical outcome
or a heterogeneous set of other psychotherapies. Twaddle studies. They conclude that the current pre-eminence of
& Scott (1991) cite work by McLean & Hakstian (1979) cognitive behavioural approaches is due ‘not only to
showing that cognitive therapy has a superior effect to all their commitment to methodological rigour but more
forms of psychological therapy given for an equivalent particularly to the failure of both analytic and humanistic
time. approaches’ to withstand similar examination (Newell &
It should be acknowledged here that nurse therapists Dryden 1991, p. 20).
already have a published record for performing random- Finally, these techniques are widely applicable to most
ized controlled trials in the treatment of several conditions. psychiatric disorders and continue to find new applications
For example, Deale et al. (1997) considered chronic fatigue with a broad range of populations in a variety of settings
syndrome, Gournay studied body image disorder (Gournay (Hawton et al. 1989, Beck 1993), unlike, say, behaviour
et al. 1997) and agoraphobia (1991), and Lovell reported therapy and psychoanalysis, which are far more circum-
on post traumatic stress disorder (Marks et al. 1998). The scribed (Brewin 1996).
current need is for nurse therapists to extend this research
methodology to their use of cognitive therapy in the treat-
Weaknesses of cognitive behavioural approaches
ment of depression.
Beck’s original observational studies were performed on Despite this impressive list of strengths, there are also
humans rather than animals (Williams 1992, Stewart some weaknesses associated with cognitive behavioural
1994), thus negating the common criticism of behavioural approaches. Abraham et al. (1991) are critical of the poor
therapies regarding the assumption of ‘generalization design of many of the outcome studies previously men-
across species’. The therapy was initially developed specif- tioned, and suggests that many results are ‘convenient and
ically for the treatment of depression (Bemporad 1992), in self-serving’, aimed at pitching psychological therapies
contrast to behavioural and psychotherapies which have against psychopharmacological ones; that is, adopting an
been more successful in accounting for anxiety states. ‘antibiologic’ or ‘pro-psychological’ stance.
The many standardized measures used for assessment Dobson (1989) and Haaga & Davidson (1991) suggest
and evaluation purposes in cognitive behavioural ap- that empirical support for Beck’s theory of depression con-
proaches, for example, Beck’s Depression Inventory – cerning stable dysfunctional beliefs is disappointing, with
Rehm (1988) and Williams (1992) provide excellent mainly negative conclusions about the causal status of
descriptions – lend themselves to objective measurement of cognitions. The previously mentioned work of Jacobson
efficacy via repeated administration at pretreatment, post- et al. (1996) and Gortner et al. (1998) also attest to this.
treatment and follow-up points. Some authors suggest that Beck’s cognitive model pro-
The routine collection of clinical process and outcome poses that the cognitive triad (negative views of self, the
data by therapists is now becoming an essential aspect of world and the future) and maladaptive cognitive process-
practice, in order that clinicians can demonstrate impact ing of information causes and maintains depression (Nezu
and progress to clients, other clinicians and through et al. 1989, Williams 1989, Calarco & Krone 1991).
managerial audits (Dryden 1998). Hence these forms of Twaddle & Scott (1991) and Williams (1992) cite mood
evaluation would provide opportunities for nurse thera- induction exercises as analogue evidence of this potential.
pists to adopt single case study designs. In this way they However, most authors (including recently Beck himself)
could evaluate and report on individual treatment efforts are less extreme and suggest that, especially in the case of
using the variety of quantitative research methods avail- endogenous depression, ‘depresso-type cognitions are . . .
able and not feel dis-barred because large samples and characteristic of depression, not a cause of depression’
controlled conditions do not pertain. This emphasis on (Haaga & Beck 1992, p. 511). In this more moderate for-

348 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches

mulation, the role of cognitions is viewed as maintaining rather than experienced’ and add that therapists over-
depression once started (Williams 1989, Williams & emphasize rationality and neglect the potential importance
Moorey 1989, Clark & Beck 1990, Sheldon 1995). of unconscious processes. These comments are considered
This theme is also discussed by Twaddle & Scott (1991) a little harsh given the suffering and mortality that can
who rightly suggest that support for efficacy of cognitive ensue and probably serve to advance a different philo-
therapy does not establish the validity of cognitive theory. sophical standpoint.
The opportunities for subjective bias in the cognitive A final, more serious, weakness of cognitive behavioural
behavioural therapist when looking for bias in the client approaches is that they fail to convincingly explain the sub-
are listed by Salovey & Singer (1991) and include first stantial physical symptoms that accompany depression:
impressions, remembering/forgetting information and sleep disturbance, constipation, poor appetite, aches and
making clinical decisions. Similarly, Spinelli (1994) implies pains, etc., or the success of antidepressant medication.
that the objectivity of the therapist can be compromised These limitations would certainly apply to some elderly
when judging what is rational, which cognitions are to be populations, wherein Dobson (1989) suggests that the
restructured and which beliefs and values are dysfunc- nature of the symptomatology – so-called vegetative or
tional. These judgements are crucial in depression because physical signs – may indicate a preference for pharmacol-
there is some evidence (Alloy et al. 1990) that depressed ogy. Calarco & Krone (1991) point to accumulating
individuals can be more accurate or realistic in their research evidence suggesting that depression is clearly both
appraisal of the world, self, etc. (perception and inference) a psychological and biologic event.
than normal nondepressed people.
Some authors suggest that cognitive behavioural
Discussion
approaches are only suitable for reactive depression and
inappropriate for severe, psychotic depression (Stewart On the basis of the material just presented, it cannot be
1994). denied that over the last 20 years cognitive behavioural
Robins & Hayes (1993) list the following characteristics approaches have produced a great deal of optimism in
as associated with poor response or nonresponse: initial those treating depression and clearly demonstrated their
severity of depression, level of cognitive dysfunction, efficacy in many outcome studies of recovery and relapse
severe interpersonal disturbance (chronic marital discord, prevention. When properly indicated and used to their
family dysfunction, critical communication), coexisting strengths, cognitive behavioural approaches are an invalu-
personality disorder. Young (1990), cited by Robins & able tool in the armoury of treatments for depression and
Hayes (1993), accounts for some of these limitations by have much to recommend them. Further, cognitive behav-
suggesting that some of the assumptions of cognitive ioural approaches in general, and Beck’s cognitive therapy
therapy do not apply to patients with personality dis- in particular, have been willingly subjected to the most
order, for example, ‘ready access to feelings’, ‘ready detailed of clinical evaluations and exemplify the emerging
access to thoughts and images’, ‘readily identifiable target health culture of evidence-based treatment.
problems’. But what are the implications of all this effort for mental
A criticism lodged by Newell & Dryden (1991) would health nurses? A relatively small number of mental health
relate to the possible mechanistic application of techniques nurses are nurse therapists, who may well have been
with little regard for the relationship between client and trained in these techniques, but not necessarily so (Newell
therapist or the necessity for thorough assessment of the & Gournay 1994). A much larger group of nurses work in
client’s unique presentation and circumstances. community settings, have attended courses and/or gained
Most recently Brewin (1996) is critical of the poor level experience and use these techniques with clients on their
of understanding of underlying mechanisms, the absence case load or day hospital clients. As previously indicated,
of a single recognizable strand of basic psychological many more mental health nurses work extensively in insti-
research and theory, and the differences in terms used by tutional settings with patients who may benefit from cog-
different cognitive behavioural approaches to describe the nitive behavioural approaches to their problems. However,
cognitive functioning of clients. Brewin (1996, p. 37) con- should these nurses, who do not possess recognized thera-
cludes that ‘the different cognitive theories and therapies, pist qualifications and who are unlikely to get them in large
let alone cognitive and behavioural therapy, clearly share numbers, utilize these approaches, or is a long, arduous
no theoretical unity’. and exclusive preparation an essential prerequisite to their
Emery & Tracy (1987) cite Mahoney (1980), who sug- safe application?
gests that cognitive behavioural approaches are restricted As identified in an earlier section, there are currently
in that they view emotions ‘as something to be controlled only 363 registered cognitive therapists in the UK. Should

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354 349
B. F. Beech

the use of cognitive therapy and cognitive behavioural involved with suicidal patients and had communication
approaches be restricted to this small number of therapists? difficulties.
Such an elitist standpoint would result in untenable statis- Carrigan (1994), on the basis of patient interviews,
tics and have no impact on the total amount of depressed advocates that nurses should offer support and enhance
people who could respond (and would prefer to be treated) self-esteem. Further, a need for more patient involvement
with this approach. As the approach becomes more and a wider use of therapies ‘geared towards assisting the
popular and, hence, demanded by clients, crude arithmetic patients to cope with and come to terms with their prob-
shows that chaos and disappointment would ensue. For the lems are required’ (Carrigan 1994, p. 640). Good com-
UK, 2 million depressed clients each year demanding and munication is stressed as the key to improvement, a theme
receiving 20 sessions of cognitive therapy results in a total also identified by Reid & Long (1993). In their study,
of 40 million sessions. Delivered by 363 accredited and nursing staff expressed a need for further training and
registered cognitive therapists this equates to a little over better preparation in interacting and communicating with
100 000 sessions per therapist per year or 400 one-hour depressed patients who were receiving special levels of
sessions per therapist per working day. observation.
The inclusion of other groups, such as suitably skilled
clinical psychologists and nurse therapists, does little to
Greater utilization of cognitive behavioural
improve these figures. If, say, 1500 suitably qualified
approaches
therapists treat the same 2 million depressed clients, then
this results in over 25 000 sessions per therapist per year Here it is intended to present the case that some of the pur-
or 100+ sessions per working day. And this simplistic cal- ported strengths of cognitive behavioural approaches make
culation excludes all the competing problem areas for the it perfectly feasible and desirable for mental health nurses
application of cognitive behavioural approaches, including to utilize cognitive behavioural approaches in both formal
panic disorder with agoraphobia, obsessive compulsive and informal interactions with patients. Figure 2 provides
disorder, social phobia and so on, which still form the a summary of the factors considered relevant.
majority of their caseloads. Mental health nurses have the presence, the contacts and
In addition it would negate the pragmatic reality of the core skills necessary. They have some familiarity with
NHS mental health provision wherein hundreds, if not psychological models, interaction and communication
thousands, of mental health nurses use cognitive and skills and access to further specialized literature and con-
behavioural approaches in hospital-based and community tinuing training and staff development (Peck & Norman
settings on a daily basis, for example, when they devise and 1999). The professional requirement for nurses to under-
deliver formal depression or anxiety management pro- take continuing development and education as part of the
grammes to individuals or groups of clients. re-registration process provides an opportunity for the
But what of many other mental health nurses who have training and skills development identified in the research
protracted contacts with patients suffering from depres- of Reid & Long (1993) above. There may well be scope
sion? When providing higher levels of close observation to here for this provision to be incorporated into multi-
patients assessed as being at risk on acute admission wards, disciplinary training initiatives. This approach would align
for example, or when sitting informally discussing the with the recent Sainsbury Centre report entitled Pulling
present and the future with clients in rehabilitation and Together (Sainsbury Centre for Mental Health 1997),
elderly care settings. which espouses the ideas of core competencies and multi-
disciplinary training for the development of community
mental health care provision. It could also have a contem-
The close observation scenario
porary resonance with the emerging Higher Education
Fletcher (1999) provides many examples from the nursing philosophy for shared learning and common modules
literature of assertions that close or constant observation between different departments within an institution. It
should be viewed as having a therapeutic purpose. could be that departments of counselling, nursing, psychi-
Yet nurses have been viewed as being unsympathetic, atry, psychology and social work co-operate in the creation
punitive and avoidant, for fear of saying something that and delivery of multi-professional modules on cognitive
makes matters worse. A study by Duffy (1995) showed behavioural approaches of varied levels and duration. The
nurses performing special observation of patients made main obstacle to this could well be the resistance from the
little attempt at ‘treatment’, preferring to ‘assess’ or pass various professional organisations (King’s Fund London
time by distraction. McGaughey et al. (1995) also sug- Commission 1997) but it should be acknowledged that a
gested that nurses were unable or unprepared to become move to common aspects of role-generic working has

350 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches

Figure 2
Summary of relevant factors: Depression, Mental
Health Nurses, CBT

occurred in community mental health settings (Norman & already be behaving therapeutically, in a CBT sense,
Peck 1999). without necessarily being aware of it. Mental health nurses
A further obstacle could be the perceived potential risk will also have supervision frameworks in place and these
associated with the cascade of skills to a wider group and could be developed to provide more specialized cognitive
the resulting dilution of expertise to a potentially danger- behavioural supervision, if this was felt appropriate. Again
ous degree. Yet this process, which could be perceived by a cascade model offers a possible solution.
some as dangerous ‘proletarianization’ is in keeping with Finally many mental health nurses working in acute
the cognitive therapy philosophy, whereby clients are equal admission settings may well have already formed a good
partners, indeed ‘collaborators’, and skills and techniques relationship or ‘therapeutic alliance’ with the client that
are ‘given away’, rather than being wrapped in mystery and they are subsequently spending large amounts of time with.
closely guarded by therapists. Hence they may be able to foreshorten the time needed to
Because nurses are present with patients and do talk to produce any therapeutic effect.
them, surely it is desirable to make this conversation more Several of the previously identified strengths of cognitive
predictably therapeutic? Casual observation of nurse– behavioural approaches also support the argument for
patient interactions reveals many examples of healthy wider application by staff who are not cognitive therapists,
thinking being demonstrated. It is apparent that particular such as the relatively straightforward model that is clearly
cognitive behavioural techniques, for example, hypothesis explicated along with detailed descriptions of how and
testing, alternative thinking, examining advantages and when to use techniques along with what to do when things
disadvantages and looking for positives are routine and do not run to plan (Hawton et al. 1989, Williams 1992).
‘intuitive’ for many pragmatic nursing staff without the The evidence that self-help and bibliotherapy materials
need for formal cognitive therapy training. Hence they may have demonstrable effectiveness reinforces this point. Staff

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354 351
B. F. Beech

could use these materials for training purposes and also sion: a reanalysis of the NIMH TDCRP. Journal of Affective
assist with their utilization by patients. Disorders 43, 181–186.
Alloy L.B., Albright J.S., Abramson L.Y. & Dykman B.M. (1990)
Williams (1989) anticipated a ‘package of ingredients’
Depressive realism and non-depressive optimistic illusions: the
for wide use by less specialized staff and Jacobson et al. role of the self. In: Contemporary Psychological Approaches to
(1996) and Gortner et al. (1998) have demonstrated that Depression (ed. Ingram R.E.), pp. 71–86. Plenum Press, New
a full cognitive therapy programme is not necessarily York.
required. Gortner et al. (1998) suggest that relatively Barker P. (1998) The behavioural therapies. Nursing Times 94,
uncomplicated components of cognitive therapy (behav- 44–46.
Barkham M., Moorey J. & Davis G. (1992) Cognitive-
ioural activation strategies) may be more accessible and
behavioural therapy in two-plus-one sessions: a pilot field
better suited to use by para-professionals or being self- trial. Behavioural Psychotherapy 20, 147–154.
administered, and could be highly cost-effective. Campbell Beck A.T. (1976) Cognitive Therapy and the Emotional Dis-
(1992) showed that one aspect of cognitive therapy, in this orders. New American Library, New York.
case diary-keeping, could be taken and utilized by mental Beck A.T. (1993) Cognitive therapy: past, present and future.
Journal of Consulting and Clinical Psychology 61, 194–198.
health nurses with a significant effect on depressive symp-
Bemporad J.R. (1992) Psychoanalytically oriented psychotherapy.
toms in elderly persons. Finally, readily available assess- In: Handbook of Affective Disorders, 2nd edn (ed. Paykel E.S.),
ment documents would provide evidence to both staff and pp. 465–473. Churchill Livingstone, London.
patient that progress was being made. Bergin A.E. & Garfield S.L. (1994). Handbook of Psychotherapy
and Behavior Change, 4th edn. John Wiley and Sons. New
York.
Conclusion Blackburn I.M. & Moore R.G. (1997) Controlled acute and
follow-up trial of cognitive therapy and pharmacotherapy
This article has presented a summary of the reported in out-patients with recurrent depression. British Journal of
strengths and weaknesses of cognitive behavioural ap- Psychiatry 171, 328–334.
proaches to the treatment of depression. It has been sug- Blatt S.J., Sanislow C.A., Zuroff D.C. & Pilkonis P.A. (1996)
gested that cognitive behavioural approaches have a Characteristics of effective therapists: further analyses of data
proven track record in this area and have much to from the NIMH TPCRP. Journal of Consulting and Clinical
Psychology 64, 1276–1284.
recommend them.
Brewin C.R. (1996) Theoretical foundations of cognitive-
The article attempts a simplistic estimation of the current behavior therapy for anxiety and depression. Annual Review of
use of the approaches by different therapist groups and Psychology 47, 33–57.
compares this with the possible impact on potential Calarco M.M. & Krone K.P. (1991) An integrated nursing model
demand. It then identifies a current area of reported of depressive behavior in adults. Nursing Clinics of North
America 26, September, 573–584.
difficulty for mental health nurses working in inpatient
Campbell J.M. (1992) Treating depression in well older adults:
settings, as adjudged by staff and clients. Finally it suggests use of diaries in cognitive therapy. Issues in Mental Health
that brief training in aspects of cognitive behavioural Nursing 13, 19–29.
approaches would offer mental health nurses (and poten- Carrigan J.T. (1994) The psychosocial needs of patients who have
tially other mental health care professionals) a straight- attempted suicide by overdose. Journal of Advanced Nursing
forward framework for therapeutic communication and 20, 635–642.
Clark D.A. & Beck A.T. (1990) Cognitive therapy of anxiety and
interaction with patients during periods of protracted
depression. In: Contemporary Psychological Approaches to
contact, such as, say, those that accompany constant obser- Depression (ed. Ingram R.E.), pp. 155–167. Plenum Press, New
vation regimes. Further, the development of skills in this York.
area would meet the needs that are being expressed by both Deale A., Chalder T., Marks I. & Wessely S. (1997) Cognitive
sides for better communication and interaction without behavior therapy for chronic fatigue syndrome: a randomised
controlled trial. American Journal of Psychiatry 154, 408–414.
exhaustive theoretical preparation.
Dobson K. (1989) A meta-analysis of the efficacy of cognitive
therapy for depression. Journal of Consulting and Clinical
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