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

© 2000 Blackwell Science Ltd 343

B. F. Beech
In this article it is intended to consider the following
series of contentions:
• Depression is a major mental illness that places great
demands on primary and specialist care services.
• Cognitive therapy [or cognitive behavioural therapy]
delivered by cognitive therapists is an effective treat-
ment for depression.
• There are only a small number of registered cognitive
therapists in the UK (minute in comparison with the
scale of the problem).
• Nurse therapists, psychologists and many mental
health nurses working in day hospital and community
settings successfully use cognitive behavioural appro-
aches with clients on their case-loads.
• Many other mental health nurses have multiple pro-
tracted interactions each day, both formal and infor-
mal, in varied settings, with patients suffering from
depression
• Cognitive behavioural approaches to depression
(aspects or components of cognitive therapy) can be
competently and effectively utilized by mental health
nurses working in varied hospital and community-
based NHS settings.
Before these ideas are developed further it is firstly
intended to provide a little more background on depres-
sion, mental health nursing and cognitive behavioural
therapy and then review the purported strengths of cogni-
tive behavioural approaches to depression. The disparate
findings and assertions of authoritative writers and re-
searchers on CBT are reported in a way that allows readers
to consolidate their understanding of the potential for
using cognitive therapies in the treatment of depression.
Background
Depression
Depression is frequently referred to as ‘the common cold
of psychopathology’ (Williams 1989, Calarco & Krone
1991) and this phrase accurately suggests its prevalence but
seriously under-states many of its other characteristics and
effects. Depending on the definition of depression adopted,
it is frequently reported that 1 in 1000 of the general
population will be hospitalized with depression each year,
whilst a further 2 in 1000 will be referred to a psychiatrist
as outpatients (Paykel 1989, Gilbert 1992). The pos-
sible effects of recent hospital closures and transition to
community-based care on these figures are not known.
The prevalence rate of serious depression in the general
population is about 5% although estimates vary widely
(Paykel 1989). In the UK each year, between 3 and 10%
of the population will seek treatment from other sources,
344 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
General Practitioners, Social Workers or Counsellors
(Gilbert 1992). These figures translate as 1.5–5 million
people in the UK suffering severe depression each year. In
addition, many depressed people will not seek assistance
and, of those that do consult, the disorder may not be
recognized in many cases.
Gilbert (1992, p. 3) states that estimates suggest that ‘as
many as 1 in 4 or 5 will have an episode of serious depres-
sion warranting treatment at some point in their lives’ and
cites a figure of 100 million depressed people worldwide.
Depression is recognized as the major factor implicated
in suicide (DoH 1992). Hammen (1997) suggests that
diagnosable depressive disorders are implicated in up to
60% of suicides and adds that 10–15% of individuals
with major depressive disorder eventually kill themselves.
During 1991, depression is estimated to have cost $29
billion in the United States in absenteeism, suicides and
treatment costs (Abraham et al. 1991), and it is also a
source of intense despair to millions of people around the
world.
Mental Health Nurses
Mental health nurses are present in most, if not all, mental
health environments in the UK and, indeed, in most of
these settings, have the largest professional presence. Addi-
tionally, they would be distinguished from colleagues by
having a continuous 24 h presence in institutional settings
– for example, in acute admission, rehabilitation and
elderly assessment wards, and some community mental
health centres.
Many mental health nurses working in community
mental health or primary care teams and settings have
gained some appropriate training and expertise and use
cognitive behavioural approaches with clients on their
caseloads. This article will attempt to underpin and legiti-
mate the reality of clinical work for these nurses.
Moreover, in institutional settings, inpatients who are
diagnosed as suffering from depression will have frequent
or continuous contact with nursing staff detailed in their
care plans as part of observation policies, if for no other
reason (Reid & Long 1993, Duffy 1995, Moore et al.
1995, Fletcher 1999). Hence, it could be argued that many
opportunities exist for a large proportion of the work force
to interact therapeutically, in both individual and group
contexts, with a major client group that place heavy
demands on the psychiatric services.
Whilst staff will talk to and interact with clients, the style
of interaction ranges from unhelpful/destructive/con-
trolling actions (sitting outside, sitting in silence, ‘backing
off’; Fletcher 1999) through neutral ‘chit-chat’ (‘passing of
time’; Duffy 1995) to helpful/therapeutic dialogue and

activity (Reid & Long 1993). A recent publication en-
titled ‘Acute Problems’ found a ‘care vacuum’ on acute
psychiatric wards for 30% of patients who engaged in no
activity, therapeutic or recreational, during their stay
(Sainsbury Centre for Mental Health 1998).
Most of these nursing staff currently do not possess, and
probably will never obtain, any recognized specialist
therapist qualifications, since the system currently values
other skills more highly (e.g. maintenance of safe environ-
ments, administration and management of medication). A
clear, uncomplicated framework is needed on which to
base therapeutic activity and, in so doing, maximize the
benefits of the undoubtedly numerous opportunities that
arise. Later it will be argued that, given certain aspects
of the review of cognitive behavioural therapies, large
numbers of mental health nurses, including many working
in institutional settings, whilst not being registered as ther-
apists, are nevertheless well placed to use straightforward
cognitive behavioural techniques to enhance and structure
their interactions with clients. In this way the balance
between unhelpful, neutral, and helpful interactions could
be dramatically shifted in the therapeutic direction.
Cognitive Behavioural Therapy and Cognitive
Behavioural Therapists
Emery & Tracy (1987, p. 3) define CBT as ‘a series of
strategies that relieve psychological suffering by correcting
distorted and maladaptive thinking. The therapy is based
on a theory of psychopathology that recognizes the recip-
rocal interrelationship among the cognitive, behavioural,
somatic and emotional systems.’
An immediate initial challenge in attempting to collate
material is to manage the diversity of theoretical models
and subtle differences in clinical emphasis that charac-
Figure 1
Commonalties between models (Newell &
Dryden 1991)
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches
terize the range of therapies grouped under the CBT
heading. Nevertheless the range of cognitive behavioural
approaches are widely acknowledged as sharing some
common characteristics as specified in Fig. 1 (Newell &
Dryden 1991).
Clark & Beck (1990) summarize the differences between
approaches in terms of primary cognitive construct tar-
geted, methods used to achieve change, range of applica-
tions, and extent to which practice is derived from a
distinct cognitive model of psychopathology.
Twaddle & Scott (1991) list four models of depression,
these being the works of Beck (1976), Ellis (1970), Rehm
(1977) and Seligman (1981). In the same text, Newell &
Dryden (1991, p. 5) cite Rachman & Wilson’s (1980) iden-
tification of ‘three major schools of thought in cognitive
therapy’, these being Ellis’s Rational Emotive Therapy
(RET), Beck’s Cognitive Therapy (CT) and Meichenbaum’s
(1969) Self Instructional Therapy (SIT). Calarco & Krone
(1991, p. 575) refer to the models of Beck and Seligman
as ‘the most dominant cognitive therapies related to
depression’.
According to its own publicity material, the British Asso-
ciation for Behavioural and Cognitive Psychotherapies
(BABCP), a multidisciplinary interest group for people
involved in the practice and theory of behavioural and
cognitive psychotherapy, currently has 3000 members.
These consist of clinical psychologists, psychiatrists, social
workers, nurses, counsellors, GPs, researchers, academics
and colleagues. However, only a subset [N = 363] of
these people are currently accredited by the BABCP and
registered as cognitive/behavioural therapists with the
United Kingdom Council for Psychotherapy (UKCP) (from
personal inquiry to UKCP).
In the UK, nurse behaviour therapists will obviously
utilize cognitive behavioural therapy techniques. A 1992
345
B. F. Beech
survey of almost 150 nurse therapists (the entire output
of four training centres who were still resident in the UK
and practising as nurses) showed clients with depression
formed a part of the caseload (mean 10%) and cognitive
therapy to be the second most frequent technique used
(Newell & Gournay 1994). Less clear was the level of
preparation and training in the use of these techniques. The
latest survey, which follows up all nurse therapists to 1998,
clearly shows the continued expansion of nurse therapists
into this cognitive therapy area and the rise of depression
to the top of the list of reasons for referral (Professor
K. Gournay, personal communication). It is also estimated
that, on average, patients with depression could make
up 20 of the 70 patients treated to completion each
year by nurse therapists (Professor K. Gournay, personal
communication).
Cognitive behavioural approaches are widely admin-
istered by psychologists, psychiatrists and other pro-
fessionals. A recent estimate suggests that approximately
one-quarter to one-third of the 3000 clinical psychologists
chartered by the British Psychological Society would be
suitably skilled to provided cognitive behavioural inter-
ventions (Professor K. Gournay, personal communication).
Strengths of a cognitive behavioural approach
to treatment
The approach adopted in the following review is to assume
that comments apply generally to cognitive behavioural
approaches unless they are specifically attributed to a
particular approach.
Firstly, whilst there is continuing debate about the accu-
racy of aspects of underlying cognitive behavioural theory
(Barker 1998), there is general agreement in the clinical
literature that the techniques of cognitive behavioural
approaches to therapy are likely to be effective in treating
depression (Brewin 1996). The National Institute of
Mental Health Treatment of Depression Collaborative
Research Program (NIMH TDCRP), a large US multi-site,
multi-treatment condition study of 250 patients with
depression treated with defined treatments by selected
therapists, has been widely reported (Elkin et al. 1989,
Shea et al. 1992) and still proves a seminal study. Inter-
pretation is complex and ongoing but Elkin (1994) attests
to the comparative effectiveness of CBT in treating depres-
sion and the lack of any significant difference between
cognitive therapy, interpersonal therapy or antidepressant
medication at termination of treatment.
However, lack of significant difference did not exactly
equate to ‘equivalence’. In this study medication was found
to have a more rapid effect with significant differences
observed at 12 weeks (but not 4 weeks) and also to be par-
346 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
ticularly effective for more severely depressed patients. No
such differences were observed for less severely depressed
patients but there was a hint that psychotherapy may do
better in the longer term. In reviewing the relapse figures
for the study, Elkin (1994) suggests the possibility that
short-term treatment of depression has been ‘oversold‘,
whatever the treatment, and advises that longer periods of
initial treatment, maintenance treatments, ‘booster ses-
sions’ and integrated approaches be investigated. Analyses
of the findings of this hugely significant study continue
to be published (Blatt et al. 1996, Agosti & Ocepek-
Welikson 1997).
Hollon & Beck (1994, p. 432) conclude that evidence
from most studies (with the exception of the NIMH study)
indicates that cognitive therapy is ‘about as effective as
pharmacotherapy regardless of severity, at least among
nonpsychotic patients’.
Furthermore, its use is not contra-indicated by the pre-
scription of medication and, indeed, the two treatments
applied simultaneously may have a reinforcing effect
(Evans et al. 1992). Readers are referred to Bergin &
Garfield (1994) for a detailed discussion of these and other
related issues.
Many excellent, technically detailed texts exist, for
example Williams (1992) and Hawton et al. (1989), which
allow techniques to be communicated, standardized, repli-
cated and evaluated by other therapists (Stewart 1994).
In comparison with psychoanalysis, which is costly and
time-consuming, cognitive behavioural approaches are
shorter in duration and emphasize symptom management
(compensation) rather than insight (Abraham et al. 1991,
Spinelli 1994). A recent study by Scott et al. (1997) showed
that brief cognitive therapy for depression in primary care
(six sessions) may be beneficial whilst Barkham et al.
(1992) showed the benefits of ‘two plus one’ sessions of
cognitive therapy for depression.
Involvement of the client is one of the hallmarks of cog-
nitive behavioural approaches. An equal partnership is
actively sought in the interpretation of cognitions (unlike
psychoanalysis; see Abraham et al. 1991) and when engag-
ing in Socratic dialogue. More generally, the importance of
good client–therapist interaction is increasingly acknowl-
edged by most cognitive behavioural approaches, but not
as an end in itself. The CBT literature increasingly empha-
sizes the importance of therapeutic alliance as a precondi-
tion for successful application of cognitive techniques and
desired patient outcomes (Muran et al. 1995, Blatt et al.
1996, Raue et al. 1997).
Unlike humanistic approaches, therapist skills are valued
over particular therapist traits (Newell & Dryden 1991)
and, in this regard, Robins & Hayes (1993) conclude
that cognitive behavioural approaches are associated with

symptom reduction beyond the effects due to more general
therapy factors (empathy, warmth, etc.). This point is rel-
evant to any possible utilization by community psychiatric
nurses (CPNs). It has been demonstrated that, in samples
of clients with high levels of depression, CPNs without cog-
nitive behavioural training and using a Rogerian approach
failed to make any impact (Gournay & Brooking 1994,
Gournay & Brooking 1995).
Sheldon (1995) reports studies that find cognitive
behavioural approaches being described as ‘user-friendly’
by clients in comparison with other therapies and associ-
ates this with the lower ‘drop-out’ rate reported for this
approach by Twaddle & Scott (1991). Bemporad (1992)
and Spinelli (1994) also emphasize the focus on ‘the
present’, avoidance of hypothetical constructs such as ‘the
unconscious’, nonutilization of transference and resistance,
and instructional rather than transferential quality of the
therapist–client relationship, as strengths over the psycho-
analytic therapies.
The early presentation of the relatively simple cognitive
behavioural model to the client (Haaga & Davidson 1991)
is viewed by many as a strength in that it avoids the pos-
sible mystique and pretence of all-knowing expert status
associated with some other therapies. If the client is suffi-
ciently ‘psychologically minded’ to accept this model and
can identify strongly with cognitive explanations then they
should respond well (Twaddle & Scott 1991).
Williams (1989) reports that the approaches work across
the range of social classes (unlike psychoanalysis), whilst
Twaddle & Scott (1991) assert that lower intelligence
and endogenous depression are not necessarily contra-
indications for referral for therapy.
Whilst cognitive behavioural approaches are not
generally as directly cost-effective as antidepressant psy-
chopharmacology, being equally effective, they are of use
when medication is inappropriate. The strength of cogni-
tive behavioural approaches would be apparent when
clients will not accept medication for ideological reasons,
when it can’t be physically tolerated because of side-effects,
when cardiac toxicity prevents prescription (Williams
1992) or in tackling ‘drug resistant cognitions’ (Twaddle
& Scott 1991). For example, Moore & Blackburn (1997)
provide evidence of CT being at least partially effective
with outpatients with recurrent major depression who fail
to respond to medication.
Experimental studies have show cognitive behavioural
approaches to be superior to antidepressant medication in
preventing subsequent relapse (Williams 1989, Robins &
Hayes 1993). Evans et al. (1992), cited by Hollon & Beck
(1994), found that patients treated to remission with cog-
nitive therapy (with or without combined medication) were
less likely to relapse following termination of treatment
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches
than patients treated to remission with medication, and no
more likely to relapse than patients who were continued
on medication for the first year of the 2 years follow-up.
Blackburn & Moore (1997) showed that maintenance cog-
nitive therapy had a similar prophylactic effect to mainte-
nance medication over a two-year period.
Cost-effectiveness may be maximized by the use of group
cognitive therapy for certain conditions (Abraham et al.
1992, Stravynski et al. 1994, Wilhelm et al. 1999).
Williams (1989, p. 174) makes a second point in rela-
tion to cost, suggesting that possibly in the future research
will isolate ‘a package of active ingredients . . . for rela-
tively mild but fairly chronic depressives’ that can be
worked through by clients themselves, their GP or CPN in
a cost-effective manner. In this vein, Jacobson et al. (1996)
and Gortner et al. (1998) recently showed that CT was
effective, but no more so than its two major components
– behavioural activation (BA) or BA with automatic
thought modification – in treating episodes of major
depression. It was no more effective than its components
in preventing relapse over a two-year time period, wherein
almost half of the clients had suffered a relapse.
Computer-delivered CBT, an interesting development for
mild to moderate depression, is reported by Selmi et al.
(1990). This impressive study demonstrated that six
sessions of CBT delivered by a computer over a six-
week period was as effective as a therapist using the
same cognitive behavioural treatment protocol and that
improvement was maintained over a two-month follow-
up. Although the therapies were delivered over a relatively
brief time period ‘improvement was substantial and
equally durable for both treatment groups’ (Selmi et al.
1990, p. 55). The implication of this finding, if confirmed
by replication, is potentially revolutionary, although this
approach will always run a risk of being dismissed by some
critics as impersonal and mechanistic.
The incorporation and use of published material in,
between, or instead of, therapy sessions – bibliotherapy –
is also a cost-effective application to the treatment of
depression in association with therapist support and guid-
ance (Stevens 1996). Jamison & Scogin (1995) demon-
strated that minimal contact cognitive bibliotherapy –
reading a self-help treatment book for depression that uses
cognitive behavioural principles – was an effective treat-
ment for depression with a general adult population. The
results were both statistically and clinically significant and
improvement was maintained at a three-month follow-up.
The authors suggest that the approach could have educa-
tional, preventative and public awareness roles but Dryden
(1998) cautions that merely reading material is insufficient.
Advice from bibliotherapy has to be actively followed and
practised if it is to be effective.
347
B. F. Beech
Within the cognitive behavioural approaches, Beck’s
Cognitive Therapy (CT) has certain other recognized
strengths over and above those just identified. It is fre-
quently reported as the most widely researched psy-
chotherapy over the last 25 years (Twaddle & Scott 1991,
Robins & Hayes 1993), with ‘the most substantial empir-
ical support of all the cognitive behavioural approaches’
(Haaga & Davidson 1991, p. 268). A quantitative review
of 28 studies of outpatients by Dobson (1989) concluded
that Beck’s cognitive therapy is more effective than waiting
list controls, pharmacotherapies, behavioural treatments
or a heterogeneous set of other psychotherapies. Twaddle
& Scott (1991) cite work by McLean & Hakstian (1979)
showing that cognitive therapy has a superior effect to all
forms of psychological therapy given for an equivalent
time.
It should be acknowledged here that nurse therapists
already have a published record for performing random-
ized controlled trials in the treatment of several conditions.
For example, Deale et al. (1997) considered chronic fatigue
syndrome, Gournay studied body image disorder (Gournay
et al. 1997) and agoraphobia (1991), and Lovell reported
on post traumatic stress disorder (Marks et al. 1998). The
current need is for nurse therapists to extend this research
methodology to their use of cognitive therapy in the treat-
ment of depression.
Beck’s original observational studies were performed on
humans rather than animals (Williams 1992, Stewart
1994), thus negating the common criticism of behavioural
therapies regarding the assumption of ‘generalization
across species’. The therapy was initially developed specif-
ically for the treatment of depression (Bemporad 1992), in
contrast to behavioural and psychotherapies which have
been more successful in accounting for anxiety states.
The many standardized measures used for assessment
and evaluation purposes in cognitive behavioural ap-
proaches, for example, Beck’s Depression Inventory –
Rehm (1988) and Williams (1992) provide excellent
descriptions – lend themselves to objective measurement of
efficacy via repeated administration at pretreatment, post-
treatment and follow-up points.
The routine collection of clinical process and outcome
data by therapists is now becoming an essential aspect of
practice, in order that clinicians can demonstrate impact
and progress to clients, other clinicians and through
managerial audits (Dryden 1998). Hence these forms of
evaluation would provide opportunities for nurse thera-
pists to adopt single case study designs. In this way they
could evaluate and report on individual treatment efforts
using the variety of quantitative research methods avail-
able and not feel dis-barred because large samples and
controlled conditions do not pertain. This emphasis on
348 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
objective analysis of effectiveness has been placed in stark
contrast to psychoanalysis with its vague goals of treat-
ment, such as ‘freedom from neurotic inhibition’ and
‘greater contentment’ (Bemporad 1992).
The cognitive behavioural approaches are not ‘set’. They
continue to evolve and respond to developments in theory
and accommodate empirical findings, both from cognitive
psychology and experimental therapy (Robins & Hayes
1993) and are rightly proud of their scientific foundations
and rigour (Spinelli 1994). Newell & Dryden (1991) are
critical of psychoanalysis for its lack of empirical outcome
studies. They conclude that the current pre-eminence of
cognitive behavioural approaches is due ‘not only to
their commitment to methodological rigour but more
particularly to the failure of both analytic and humanistic
approaches’ to withstand similar examination (Newell &
Dryden 1991, p. 20).
Finally, these techniques are widely applicable to most
psychiatric disorders and continue to find new applications
with a broad range of populations in a variety of settings
(Hawton et al. 1989, Beck 1993), unlike, say, behaviour
therapy and psychoanalysis, which are far more circum-
scribed (Brewin 1996).
Weaknesses of cognitive behavioural approaches
Despite this impressive list of strengths, there are also
some weaknesses associated with cognitive behavioural
approaches. Abraham et al. (1991) are critical of the poor
design of many of the outcome studies previously men-
tioned, and suggests that many results are ‘convenient and
self-serving’, aimed at pitching psychological therapies
against psychopharmacological ones; that is, adopting an
‘antibiologic’ or ‘pro-psychological’ stance.
Dobson (1989) and Haaga & Davidson (1991) suggest
that empirical support for Beck’s theory of depression con-
cerning stable dysfunctional beliefs is disappointing, with
mainly negative conclusions about the causal status of
cognitions. The previously mentioned work of Jacobson
et al. (1996) and Gortner et al. (1998) also attest to this.
Some authors suggest that Beck’s cognitive model pro-
poses that the cognitive triad (negative views of self, the
world and the future) and maladaptive cognitive process-
ing of information causes and maintains depression (Nezu
et al. 1989, Williams 1989, Calarco & Krone 1991).
Twaddle & Scott (1991) and Williams (1992) cite mood
induction exercises as analogue evidence of this potential.
However, most authors (including recently Beck himself)
are less extreme and suggest that, especially in the case of
endogenous depression, ‘depresso-type cognitions are . . .
characteristic of depression, not a cause of depression’
(Haaga & Beck 1992, p. 511). In this more moderate for-

mulation, the role of cognitions is viewed as maintaining
depression once started (Williams 1989, Williams &
Moorey 1989, Clark & Beck 1990, Sheldon 1995).
This theme is also discussed by Twaddle & Scott (1991)
who rightly suggest that support for efficacy of cognitive
therapy does not establish the validity of cognitive theory.
The opportunities for subjective bias in the cognitive
behavioural therapist when looking for bias in the client
are listed by Salovey & Singer (1991) and include first
impressions, remembering/forgetting information and
making clinical decisions. Similarly, Spinelli (1994) implies
that the objectivity of the therapist can be compromised
when judging what is rational, which cognitions are to be
restructured and which beliefs and values are dysfunc-
tional. These judgements are crucial in depression because
there is some evidence (Alloy et al. 1990) that depressed
individuals can be more accurate or realistic in their
appraisal of the world, self, etc. (perception and inference)
than normal nondepressed people.
Some authors suggest that cognitive behavioural
approaches are only suitable for reactive depression and
inappropriate for severe, psychotic depression (Stewart
1994).
Robins & Hayes (1993) list the following characteristics
as associated with poor response or nonresponse: initial
severity of depression, level of cognitive dysfunction,
severe interpersonal disturbance (chronic marital discord,
family dysfunction, critical communication), coexisting
personality disorder. Young (1990), cited by Robins &
Hayes (1993), accounts for some of these limitations by
suggesting that some of the assumptions of cognitive
therapy do not apply to patients with personality dis-
order, for example, ‘ready access to feelings’, ‘ready
access to thoughts and images’, ‘readily identifiable target
problems’.
A criticism lodged by Newell & Dryden (1991) would
relate to the possible mechanistic application of techniques
with little regard for the relationship between client and
therapist or the necessity for thorough assessment of the
client’s unique presentation and circumstances.
Most recently Brewin (1996) is critical of the poor level
of understanding of underlying mechanisms, the absence
of a single recognizable strand of basic psychological
research and theory, and the differences in terms used by
different cognitive behavioural approaches to describe the
cognitive functioning of clients. Brewin (1996, p. 37) con-
cludes that ‘the different cognitive theories and therapies,
let alone cognitive and behavioural therapy, clearly share
no theoretical unity’.
Emery & Tracy (1987) cite Mahoney (1980), who sug-
gests that cognitive behavioural approaches are restricted
in that they view emotions ‘as something to be controlled
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Cognitive behavioural approaches
rather than experienced’ and add that therapists over-
emphasize rationality and neglect the potential importance
of unconscious processes. These comments are considered
a little harsh given the suffering and mortality that can
ensue and probably serve to advance a different philo-
sophical standpoint.
A final, more serious, weakness of cognitive behavioural
approaches is that they fail to convincingly explain the sub-
stantial physical symptoms that accompany depression:
sleep disturbance, constipation, poor appetite, aches and
pains, etc., or the success of antidepressant medication.
These limitations would certainly apply to some elderly
populations, wherein Dobson (1989) suggests that the
nature of the symptomatology – so-called vegetative or
physical signs – may indicate a preference for pharmacol-
ogy. Calarco & Krone (1991) point to accumulating
research evidence suggesting that depression is clearly both
a psychological and biologic event.
Discussion
On the basis of the material just presented, it cannot be
denied that over the last 20 years cognitive behavioural
approaches have produced a great deal of optimism in
those treating depression and clearly demonstrated their
efficacy in many outcome studies of recovery and relapse
prevention. When properly indicated and used to their
strengths, cognitive behavioural approaches are an invalu-
able tool in the armoury of treatments for depression and
have much to recommend them. Further, cognitive behav-
ioural approaches in general, and Beck’s cognitive therapy
in particular, have been willingly subjected to the most
detailed of clinical evaluations and exemplify the emerging
health culture of evidence-based treatment.
But what are the implications of all this effort for mental
health nurses? A relatively small number of mental health
nurses are nurse therapists, who may well have been
trained in these techniques, but not necessarily so (Newell
& Gournay 1994). A much larger group of nurses work in
community settings, have attended courses and/or gained
experience and use these techniques with clients on their
case load or day hospital clients. As previously indicated,
many more mental health nurses work extensively in insti-
tutional settings with patients who may benefit from cog-
nitive behavioural approaches to their problems. However,
should these nurses, who do not possess recognized thera-
pist qualifications and who are unlikely to get them in large
numbers, utilize these approaches, or is a long, arduous
and exclusive preparation an essential prerequisite to their
safe application?
As identified in an earlier section, there are currently
only 363 registered cognitive therapists in the UK. Should
349
B. F. Beech
the use of cognitive therapy and cognitive behavioural
approaches be restricted to this small number of therapists?
Such an elitist standpoint would result in untenable statis-
tics and have no impact on the total amount of depressed
people who could respond (and would prefer to be treated)
with this approach. As the approach becomes more
popular and, hence, demanded by clients, crude arithmetic
shows that chaos and disappointment would ensue. For the
UK, 2 million depressed clients each year demanding and
receiving 20 sessions of cognitive therapy results in a total
of 40 million sessions. Delivered by 363 accredited and
registered cognitive therapists this equates to a little over
100 000 sessions per therapist per year or 400 one-hour
sessions per therapist per working day.
The inclusion of other groups, such as suitably skilled
clinical psychologists and nurse therapists, does little to
improve these figures. If, say, 1500 suitably qualified
therapists treat the same 2 million depressed clients, then
this results in over 25 000 sessions per therapist per year
or 100+ sessions per working day. And this simplistic cal-
culation excludes all the competing problem areas for the
application of cognitive behavioural approaches, including
panic disorder with agoraphobia, obsessive compulsive
disorder, social phobia and so on, which still form the
majority of their caseloads.
In addition it would negate the pragmatic reality of
NHS mental health provision wherein hundreds, if not
thousands, of mental health nurses use cognitive and
behavioural approaches in hospital-based and community
settings on a daily basis, for example, when they devise and
deliver formal depression or anxiety management pro-
grammes to individuals or groups of clients.
But what of many other mental health nurses who have
protracted contacts with patients suffering from depres-
sion? When providing higher levels of close observation to
patients assessed as being at risk on acute admission wards,
for example, or when sitting informally discussing the
present and the future with clients in rehabilitation and
elderly care settings.
The close observation scenario
Fletcher (1999) provides many examples from the nursing
literature of assertions that close or constant observation
should be viewed as having a therapeutic purpose.
Yet nurses have been viewed as being unsympathetic,
punitive and avoidant, for fear of saying something that
makes matters worse. A study by Duffy (1995) showed
nurses performing special observation of patients made
little attempt at ‘treatment’, preferring to ‘assess’ or pass
time by distraction. McGaughey et al. (1995) also sug-
gested that nurses were unable or unprepared to become
350 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
involved with suicidal patients and had communication
difficulties.
Carrigan (1994), on the basis of patient interviews,
advocates that nurses should offer support and enhance
self-esteem. Further, a need for more patient involvement
and a wider use of therapies ‘geared towards assisting the
patients to cope with and come to terms with their prob-
lems are required’ (Carrigan 1994, p. 640). Good com-
munication is stressed as the key to improvement, a theme
also identified by Reid & Long (1993). In their study,
nursing staff expressed a need for further training and
better preparation in interacting and communicating with
depressed patients who were receiving special levels of
observation.
Greater utilization of cognitive behavioural
approaches
Here it is intended to present the case that some of the pur-
ported strengths of cognitive behavioural approaches make
it perfectly feasible and desirable for mental health nurses
to utilize cognitive behavioural approaches in both formal
and informal interactions with patients. Figure 2 provides
a summary of the factors considered relevant.
Mental health nurses have the presence, the contacts and
the core skills necessary. They have some familiarity with
psychological models, interaction and communication
skills and access to further specialized literature and con-
tinuing training and staff development (Peck & Norman
1999). The professional requirement for nurses to under-
take continuing development and education as part of the
re-registration process provides an opportunity for the
training and skills development identified in the research
of Reid & Long (1993) above. There may well be scope
here for this provision to be incorporated into multi-
disciplinary training initiatives. This approach would align
with the recent Sainsbury Centre report entitled Pulling
Together (Sainsbury Centre for Mental Health 1997),
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-
porary resonance with the emerging Higher Education
philosophy for shared learning and common modules
between different departments within an institution. It
could be that departments of counselling, nursing, psychi-
atry, psychology and social work co-operate in the creation
and delivery of multi-professional modules on cognitive
behavioural approaches of varied levels and duration. The
main obstacle to this could well be the resistance from the
various professional organisations (King’s Fund London
Commission 1997) but it should be acknowledged that a
move to common aspects of role-generic working has

Figure 2
Summary of relevant factors: Depression, Mental
Health Nurses, CBT
occurred in community mental health settings (Norman &
Peck 1999).
A further obstacle could be the perceived potential risk
associated with the cascade of skills to a wider group and
the resulting dilution of expertise to a potentially danger-
ous degree. Yet this process, which could be perceived by
some as dangerous ‘proletarianization’ is in keeping with
the cognitive therapy philosophy, whereby clients are equal
partners, indeed ‘collaborators’, and skills and techniques
are ‘given away’, rather than being wrapped in mystery and
closely guarded by therapists.
Because nurses are present with patients and do talk to
them, surely it is desirable to make this conversation more
predictably therapeutic? Casual observation of nurse–
patient interactions reveals many examples of healthy
thinking being demonstrated. It is apparent that particular
cognitive behavioural techniques, for example, hypothesis
testing, alternative thinking, examining advantages and
disadvantages and looking for positives are routine and
‘intuitive’ for many pragmatic nursing staff without the
need for formal cognitive therapy training. Hence they may
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 343–354
Cognitive behavioural approaches
already be behaving therapeutically, in a CBT sense,
without necessarily being aware of it. Mental health nurses
will also have supervision frameworks in place and these
could be developed to provide more specialized cognitive
behavioural supervision, if this was felt appropriate. Again
a cascade model offers a possible solution.
Finally many mental health nurses working in acute
admission settings may well have already formed a good
relationship or ‘therapeutic alliance’ with the client that
they are subsequently spending large amounts of time with.
Hence they may be able to foreshorten the time needed to
produce any therapeutic effect.
Several of the previously identified strengths of cognitive
behavioural approaches also support the argument for
wider application by staff who are not cognitive therapists,
such as the relatively straightforward model that is clearly
explicated along with detailed descriptions of how and
when to use techniques along with what to do when things
do not run to plan (Hawton et al. 1989, Williams 1992).
The evidence that self-help and bibliotherapy materials
have demonstrable effectiveness reinforces this point. Staff
351
B. F. Beech
could use these materials for training purposes and also
assist with their utilization by patients.
Williams (1989) anticipated a ‘package of ingredients’
for wide use by less specialized staff and Jacobson et al.
(1996) and Gortner et al. (1998) have demonstrated that
a full cognitive therapy programme is not necessarily
required. Gortner et al. (1998) suggest that relatively
uncomplicated components of cognitive therapy (behav-
ioural activation strategies) may be more accessible and
better suited to use by para-professionals or being self-
administered, and could be highly cost-effective. Campbell
(1992) showed that one aspect of cognitive therapy, in this
case diary-keeping, could be taken and utilized by mental
health nurses with a significant effect on depressive symp-
toms in elderly persons. Finally, readily available assess-
ment documents would provide evidence to both staff and
patient that progress was being made.
Conclusion
This article has presented a summary of the reported
strengths and weaknesses of cognitive behavioural ap-
proaches to the treatment of depression. It has been sug-
gested that cognitive behavioural approaches have a
proven track record in this area and have much to
recommend them.
The article attempts a simplistic estimation of the current
use of the approaches by different therapist groups and
compares this with the possible impact on potential
demand. It then identifies a current area of reported
difficulty for mental health nurses working in inpatient
settings, as adjudged by staff and clients. Finally it suggests
that brief training in aspects of cognitive behavioural
approaches would offer mental health nurses (and poten-
tially other mental health care professionals) a straight-
forward framework for therapeutic communication and
interaction with patients during periods of protracted
contact, such as, say, those that accompany constant obser-
vation regimes. Further, the development of skills in this
area would meet the needs that are being expressed by both
sides for better communication and interaction without
exhaustive theoretical preparation.
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