Exploring Psychosocial Interventions This essay explores Cognitive Behavioural Therapy (CBT) as one of the psychosocial interventionsthat could

be used in treatment of depressedpatients in acute psychiatric settings.

Psychosocial interventions are evidence-based andrepresent an essential part of a holistic approach to healing and reduction in risks of relapses in treatment of mental illnesses. CBT is based on quality psychotherapeutic relationship and is regarded asa well-researched and established psychosocial intervention in treatment of depression. Inpatientsbenefit from frequent therapeutic interactions with mental health nurses educated and trained in use of CBT (Evans, 2007; McNally-Forsyth, Poppe, Nash, Alarcon, & Kung, 2010).

Alex is a 76 year-old man of Yugoslavian origin who immigrated to Australia three years ago. He has low command of the English language. He liveswith his son and daughter-in-law and their two children.Alexs wife died 18 months ago. Alex was self-admitted to Concorde Centre for Mental Health (CCMH) on advice of hisconcerned son who noticed his fathers physical and psychological deterioration and social withdrawal following the death of his wife. Soon after the bereavement, Alex stopped going to the local community club and to church.Recently Alex stopped participating in any kind of social or family activities. Alexs son said that Alex had lost 10kg in weight over the last 12 months.

Upon the initial assessment Alex was diagnosed with the late life depression. It was concluded that the most likely cause of Alexs depression was the loss of his wifeand possible cultural shock / separation from the country and the culture of his origin. Some of the common psychosocial risk factors in late life depression are bereavement, lack of social support and interaction of current personal and past losses / separation (Blazer 2003; Bruce, 2002; Pilgrim, Rogers & Bentall, 2009).

After the admission to the psychogeriatric ward at CCMH, Alexwas started on antidepressant medication (ADM) therapy. According to Dimidjian et al. (2006) ADM is a well proven and effective treatment for depression; however,Alex did not show much improvement in his mental condition.The nursing staff noticed that Alex kept a low profile he neither participated in group music therapy or any other therapeutic activity, nor interacted with any of the patients in the ward but usually spent the day sitting alone in the dining room or in his bedroom instead.

I became Alexs primary mental health nurse when I joined the clinical staff of the psychogeriatric ward, which was on the fifth day of Alexs admission to CCMH. My first task was to plan, organise and developa therapeutic relationship with Alexas well as plan and implementa suitable psychosocial intervention to compliment ADM therapy in treating Alexs depression.According to Scanlon (2006) therapeutic relationship is a planned, organised and dynamic activity, and according to Wheeler (2008) a good
Djekic Zarko Page 1 of 6

qualitypsychotherapeutic relationship has a significant effect on reducing symptoms of depression and it potentiates effects of any other psychotherapy used to treat depression. After meeting Alex for the first time during morning medication round I started thinking what to do next. My initial approach to mental health nursing of Alex was based on the knowledge I gained studying nursing at university, combined with experience gained when I was nursing a depressed patient with a spinal cord injury. As the psychotherapeutic relationship between Alex and I grew, I decided to use CBT combined with ADM therapy to treat Alexs depression. CBT, supported with and founded on good quality therapeutic relationship between a patient and a mental health nurse, is an effective psychosocial intervention that improves the outcomes in treating diagnosed depression in older adults. Other psychosocial therapies that could have been usedfor treating Alexs depression were: Mindfulness, Interpersonal Psychotherapy [IPT] and Guided Imagery. However, at the time, I had no previous experience to safely and efficiently use these psychosocial therapies,and, in addition,an apparent language barrier existed between Alex and the clinicians who were experienced in using these psychosocial therapies (Benson & Thistlethwaite, 2009; Elkin et al., 1995; Mor & Haran, 2009).

Within the next few days Alex and I established a rapport based on the old country themes whichfurther developed the therapeutic relationship and therapeutic alliance between Alex and me. Once the quality therapeutic relationship had been established Alex and I started collaboratively utilising our time together through brief sessions of high-yield CBT, modified for Alexs age, inherited culturally specific circumstances and social context. These modifications were: case conceptualisation, in relation to cohort beliefs, role investment, and intergenerational links, modified focus on Alexs key cognitions and beliefs that might interfere with therapy, such as loss and transition or stigma of mental illness (Andary et al., 2003; Benson & Thistlethwaite, 2009; Clarkson, 2010; Evans, 2007).

When deciding and planning which psychosocial intervention to use in treating a patient from a different culture the clinicians need to be aware that cognition, behaviour and emotions are cultural phenomena. Different cultures have different norms of what is appropriate and acceptable behaviour. In Western Medicine CBT is based on the power of an individual separate from their social context, and CBT relies on the power of the mind being of more importance than the body, relationship, society or spirit (Benson & Thistlethwaite, 2009, p.68), which is characteristic approach to use of CBT in individualistic (i.e. western) culture. However, Alex came from a more collectivistic Yugoslavian culture and I had to modify this approach to CBT when I decided to use it in addressing Alexs depression (Andary, Stolk, & Klimidis, 2003). These modificationsof CBT were focused on discussing various customs and traditions ofAustralian cultureaffecting Alexs lifewithin his social context. Alex most often discussed his disappointment that his late wife was not buried in our cemetery, according to his ancestral religious beliefs and traditions, or why his son and daughter-in-law daughter in law (who was Australian born) could not take him to his wifes resting place every Sunday the way it is done in the old country. By discussing and realising that the source of the problem and of Alexs depressiondoes not stem from Alex himself but from the challenge of dealing with differences in practices and traditions of the two cultures, i.e. Australian and Yugoslavian, Alex become cognisant of the possibilityof adaptingthe way he
Djekic Zarko Page 2 of 6

thinks andthen deciding whether to alter his behaviour or not(Andary et al., 2003; Benson & Thistlethwaite, 2009).

According to Bower and Barkham (as cited in Pilgrim, Rogers & Bentall, 2009) patients establish psychotherapeutic relationship with a mental health nurse much easier if the nurse speaks a language that the patient understands. Alex and I shared a common Yugoslavian cultural,ethnic and linguistic backgroundwhich respectively enabled us to communicatein the same language. I understood Alexs emotional experience within its socio-cultural and linguistic context, without meaning or information being lost in translation, a feature sometimes commonly present when experiences and emotions are communicated across cultural and linguistic boundaries (Andary et al., 2003). Time spent in conversations with Alex gave me the opportunity to learn more about Alex and to get to know him as a person. Recent studies found that patients with depression relate more readily to nurses who know their patient as a person and whoare thus able to understand and relate to the patient (Hanson & Scogin, 2008; Scanlon, 2006; Shattell, Starr, & Thomas, 2007).

Ethical implications ofdeveloping the psychotherapeutic relationship between Alex and me, and using CBT to treat Alexs depression were: providing safe and quality nursing, protecting the confidentiality of information, respecting the professional boundaries and cultural safety (Australian Nursing and Midwifery Council [ANMC] 2008). These ethical implications were based on the principles of ethical care i.e. autonomy, beneficence, non-maleficence, justice, confidentiality and veracity (Staunton & Chiarella, 2008). Development of psychotherapeutic relationship between a patient and a mental health nurse and application of CBT are processes that are conductive to disclosing patients confidential information, and personal strengths and weaknesses. Inappropriately developed psychotherapeutic relationship and lack of knowledge and skills in using CBT could result in crossing the professional boundaries, developing of patient-nurse dependability and could be harmful to both the patient and the nurse (Happel et al., 2008; Wheeler, 2008). I first learned the theory behind CBT while studying Psychology and Andragogy courses when I was a student/an army officer-cadet at The Military University in Belgrade, former Yugoslavia, between 1976 and 1980. I further developed my skills in using CBT during my active duty as an army officer between 1980 and 1993 when I often needed to apply CBT in working with young conscribed servicemen.I used CBT in an effort to help servicemen adjust to new environment and to overcome general anxiety, separation anxiety, grief andemotional distress during their time in national service as well as during the 1991/1993 civil war in Croatia. Between 2008 and 2010 I further advanced my skills in CBT when I was nursing a depressed patient with spinal cord injury.

The use of CBT in treatment of depression, and the connection between CBT and patients continued improvement and reduction in risk of relapse is well researched and established in many random controlled trials, meta analyses and systematic reviews (Evans, 2007;Fava et al., 2004;National Institute for Health and Clinical Excellence, 2009; Pinquart & Sorensen, 2001; Serfaty, 2009; Wilson, Mottram, & Vassilas, 2008).CBTwas developed by Aaron
Djekic Zarko Page 3 of 6

Temkin Beck in the early 1970s. CBT is time-limited and flexible collaborative psychotherapythat is based on good quality therapeutic relationship between a clinician and a patient. CBT is goal orientated in order to reduce or eliminate negative symptoms through understanding, influencing and changing thoughts, behaviours and emotions (Beck, 1979).There are different models used in CBT (e.g. cognitive therapy, rational emotive behaviour therapy, cognitive behaviour modification, computer-aided CBT) and different techniques (e.g. Socratic questioning, problem solving, coping cards, symptoms and emotions diaries).Most of CBT approaches include recognising trigger events, feelings, thoughts and behaviours, followed by challenging unwanted thought processes and exercising new ways of responding to trigger events(Happel, Cowin, Roper, Foster, & McMaster, 2008; McNallyForsyth et al., 2010).

According to Evans (2007), psychosocial therapies such as CBT have not been traditionally used in treating inpatients in acute psychiatric settings and, true enough, there were no CBT protocol manual, clinical guidelines or anything similar that I could have used to develop the plan for CBT to treat Alexs depression. However, there was enough literature at the ward about depression as well as the Protocol for treating depression, which I read with great and detailed interest. I also read the self-assessment forms (The Health of the Nation Outcome Scales [HoNOS]) which Alex completed during this first three days in the hospital. Despite the lack of adequate clinical guidelines or adequate clinical supervision in use of CBT in general and specifically in treating depression in geriatric patients, Alex and I utilised many of our daily encounters as brief sessions of high-yield CBT. These brief sessions of CBT were not structured according to any guidelines but were self-generating based on Alexs perception and observations of wards activities, our discussion about these activities and Alexs consequent engagement in the ward group activities and interaction with a few other patients. Alex expressed a strong desire to reconnect with his church community where he would find additional support and have an opportunity to meet his cultural needs. At the end of the third week Alex was assessed by the members of a multidisciplinary team and then discharged from the CCMH. On the day when he was being discharged from the hospital Alex completed another HoNOS self-assessment questionnaire, which indicated his recovery from depression through improvement in symptoms and outcomes which are correlated to improvement in quality of life (McPherson, Evans, & Richardson, 2009). CBT, in treating depression, is an effective, well-researched and evidence based psychosocial therapy focused on influencing changes in a patients emotions through understanding connections and effects between thoughts, behaviours and emotions. Through CBT the patient learns how he/she can change the way he/she feels by adapting to or changing his/her ways of thinking and behaviour.

Djekic Zarko Page 4 of 6

Reference:

Andary, L., Stolk, Y., & Klimidis, S. (2003).Assessing mental health across cultures. Bowen Hills, QLD: Australian Academic Press. Beck, A.T. (1979).Cognitive therapy and the emotional disorders. New York, NY: Penguin Books. Benson, J., & Thistlethwaite, J. (2009).Mental health across the cultures: A practical guide for health professionals. Oxford: Redcliffe Publishing. Blazer, D. G. (2003). Depression in late life: Review and commentary. The Journals of Gerontology, 58A(3), 249-265. Bruce, M. L. (2002). Psychosocial risk factors for depressive disorders in late life. Biological Psychiatry, 52, 17584. Clarkson, P. (2010).The therapeutic relationship (2nd ed.).London: Whurr Publishers. Code of ethics for nurses in Australia. (2008):Australian Nursing and Midwifery Council (ANMC). Retrieved August 6, 2011, from: http://www.anmc.org.au/userfiles/file/research_and_policy/codes_project/New%20Co de%20of%20Ethics%20for%20Nurses%20August%202008.pdf Depression: treatment and management of depression in adults. (2009): NICE guidelines reference CG90, Retrieved August 6, 2011 from: http://www.nice.org.uk/nicemedia/pdf/CG90NICEguideline.pdf Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., Jacobson, N. S. (2006).Randomized tria l of behavioural activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting Clinical Psychology, 74, 658-670. Elkin, I., Gibbons, R. D., Shea, M. T., Sotsky, S.M., Watkins, J. T., & Pilkonis, P. A. (1995). Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting Clinical Psychology, 63,841-847. Evans, C. (2007). Cognitive behavioural therapy with older people. Advances in Psychiatric treatment, 13, 111-118. Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., Grandi, S. (2004). Six -year outcome of cognitive behavioural therapy for prevention of recurrent depression. American Journal of Psychiatry, 161(10), 1872-1876. McNally-Forsyth, D., Poppe, K., Nash, V., Alarcon, R. D., & Kung, S. (2010). Measuring changes in negative and positive thinking in patient with depression. Perspectives in Psychiatric Care, 46(4), 257-265.
Djekic Zarko Page 5 of 6

McPherson, S., Evans, C. & Richardson, P. (2009). The NICE Depression Guidelines and the recovery model: Is there an evidence base for IAPT? Journal of mental health, 18(5), 105-414. Hanson, A. E, & Scogin, F. (2008). Older adults acceptance of psychological, pharmacological, and combination treatments for geriatric depression. Journal of Gerontology Series B Psychological Sciences and Social Sciences, 63(4), 245248. Happel, B., Cowin, L., Roper, C., Foster, K., & McMaster, R. (2008).Introducing mental health: A consumer-oriented approach. Crows Nest, NSW: Allen and Unwin. Mor, N. & Haran, D. (2009). Cognitive-behavioural therapy for depression. Israel Journal of Psychiatry and related Sciences, 46(4), 269-173. Pilgrim, D., Rogers, A., & Bentall, R. (2009). The centrality of personal relationship in the creation and amelioration of mental health problems: the current interdisciplinary case. Health An Interdisciplinary Journal for the Social Study of Health, Illness and medicine, 13(2) 235-254. Pinquart, M. & Sorensen, S. (2001). How effective are therapeutic and other psychosocial interventions with older adults? A Meta-analysis. Journal of Mental Health and Aging, 7(2), 207-243. Scanlon, A. (2006). Psychiatric nurse perceptions of the constituents of the therapeutic relationship: a ground theory study. Journal of Psychiatric and Mental health Nursing, 1, 319-329. Serfaty, M. A., Haworth, D., Blanchard, M., Buszewicz, M., Murad, S., & King, M. (2009). Clinical effectiveness of individual cognitive behavioural therapy for depressed older people in primary care. A Randomised controlled trial. Archives of General Psychiatry, 66(12), 1332-1340. Shattell, S. S., Starr, S. S., & Thomas, S. P. (2007). Take my hand, help me out: Mental health service recipients experience of the therapeutic relationship. International Journal of mental Health Nursing, 16, 274-284. Staunton, P., & Chiarella, M. (2008).Nursing and the law (6 ed.). Marrickville, NSW: Elsevier. Wheeler, K. (2008).Psychotherapy for the advanced practice psychiatric nurse. St Louis, Missouri: Mosby. Wilson, K. C. M., Mottram, P. G., & Vassilas, C. A. (2008). Psychotherapeutic treatments for older depressed people. Cochrane Database Systematic Review, 1(1), CD004853.

Djekic Zarko Page 6 of 6