VOL: 97, ISSUE: 03, PAGE NO: 34
Graham Paley, PhD, BSc, CPN, RMN, is a research fellow at the centre for the Analysis of Nursing Practice, Leeds Community and Mental Health Services Teaching NHS Trust/Leeds Metropolitan University
David Shapiro, PhD, MSc, BA, FBPsS, CPsychol, is a research professor at the University of Leeds
The National Service Framework (NSF) (Department of Health, 1999a) sets out the current government strategy for all aspects of mental health for adults under the age of 65. One of the key elements of the framework is patient access to and provision of psychological therapies - clearly issues that directly concern mental health nurses.
The NSF attempts to be evidence based wherever possible and specifically mentions that the effectiveness of some therapies is supported by empirical evidence. These include dialectical behaviour therapy (DBT), cognitive behaviour therapy (CBT), and psychosocial interventions (PSI) for people with schizophrenia, which are often derived from CBT principles.
There is a shortage of mental health nurses adequately prepared to deliver CBT, and only 10% of mental health nurses have so far received adequate training in providing PSI (Brooker, 1999). This leaves the majority of mental health nurses with no training in ‘evidence-based’ interventions. The NSF states that staff training is needed but full implementation of the framework is expected to take between five and 10 years.
So where does this leave those mental health nurses who are currently offering psychological interventions to their patients which they feel may not be evidence based?
Many mental health nurses, especially CPNs, are involved in counselling, which can range from informal chats through to structured, one-to-one psychotherapy sessions. It is likely that the majority of mental health nurses, while not specifically trained in CBT, will have received some training in psychological interventions, often using non-directive or client-centred methods. Many will also have undertaken postregistration training in other models of counselling or psychotherapy.
Although there is a great deal of research into CBT, other models - especially humanistic or experiential therapies - are much less well researched (Greenberg et al, 1994). The evidence that supports CBT is a testament to the utility of the model. However, nurses involved in counselling who do not use CBT may be surprised to learn that there is a wealth of research evidence to support the use of alternative models.
A comforting paradox
One of the most consistent findings from 30 years of psychotherapy research is that models of psychotherapy achieve broadly similar outcomes, despite varying in their theoretical orientation. This is referred to as the ‘equivalent outcomes paradox’ (Stiles et al, 1986).
Different models of psychotherapy have both ‘specific’ and ‘non-specific’ effects. Specific effects are those factors unique to each model, such as the identification of negative thoughts in CBT or making interpretations between past and present relationships in psychodynamic psychotherapy. However, these specific techniques are estimated to account for only 12%-15% of the variance across therapies (Lambert, 1992).
Non-specific effects are the common factors present in all models of psychotherapy, irrespective of theoretical orientation. These include understanding, warmth, the instillation of hope and of feeling supported, as well as the ‘ritual’ associated with the provision of therapy.
Lambert and Bergin (1994) suggest that non-specific factors are one of the largest mediators of outcome and ‘should not be viewed as theoretically inert or trivial’. One of the most important of these common factors is the quality of the therapeutic alliance formed between the client and the therapist, which is strongly predictive of the outcome of the therapy (Roth and Parry, 1997).
An example of the equivalent outcomes paradox is provided by a large US study that compared the effectiveness of four treatments for depression: CBT; interpersonal therapy; imipramine plus clinical management; and a placebo plus clinical management. The study found that imipramine was the most effective treatment. The two psychotherapies came a close second, with virtually no difference in effectiveness between them and little evidence for the specific effects of either of the two therapies (Elkin et al, 1989).
Even where differences are found between different psychotherapies, they can often be explained by what is termed ‘investigator allegiance’. For example, a researcher comparing CBT with psychodynamic therapy is likely to find that CBT is the most effective treatment if their allegiance is to CBT, and vice versa if their allegiance is to psychodynamic models.
A recent study showed that investigators’ own allegiance to the treatments under comparison is strongly predictive of the outcome and accounts for 69% of the variance in outcomes of comparative studies (Luborsky et al, 1999).
All counselling is potentially evidence based
These findings on the equivalent outcomes paradox, the importance of non-specific effects and investigator allegiance suggest that the most competently administered forms of counselling provided by mental health nurses could be seen as being evidence based, even if there is no direct evidence to support the specific models used.
Roth and Parry (1997) state that ‘where research has not been undertaken, absence of evidence for efficacy is not evidence of a lack of efficacy’. Additionally, they conclude that it would be premature to limit psychological interventions to ‘brand name’ therapies at the expense of further investigating pan-theoretical factors, especially the therapeutic alliance and therapist skill.
However, mental health nurses cannot become complacent about the quality of their counselling. It has been suggested that the effects of the individual therapists themselves are a major source of variation within psychotherapy studies and that studies are probably measuring the effectiveness of therapists as much as they are the effectiveness of actual therapies (Shapiro et al, 1995; Roth and Parry, 1997).
The existing research findings assume an inherent degree of therapy skills. Unfortunately, it cannot be assumed that a mental health nurse’s training will provide the skills needed to be a proficient counsellor or therapist. There is evidence that therapeutic skills are often sadly lacking among mental health nurses.
The Standing Nursing and Midwifery Advisory Committee report (Department of Health, 1999b) concluded that a lack of therapeutic interventions was common in many inpatient units. A survey published recently in Nursing Times suggests that almost 25% of community mental health nurses feel they do not relate well to their clients (Burnard et al, 2000). Fadden (1998) argues that many nurses undertaking PSI training lack even the most basic therapeutic skills.
Mental health nurses do not need to feel intimidated or insecure if they have not received specialist training in CBT or DBT - there is plenty of research evidence that clearly indicates the therapeutic value of other models.
Research suggests that any form of counselling that: leads to the development of a therapeutic relationship between nurse and client; offers some form of structure to the counselling and attends to changes or problems in the therapeutic process between nurse and client throughout the course of the counselling could justifiably be regarded as evidence-based. However, this is dependent on the nurse having sufficient clinical skills to adequately deliver these factors.
The issue of skills is crucial both to counselling and other therapeutic activities undertaken by mental health nurses. Mental health nurses should be using evidence-based psychological interventions whenever possible. These are probably best not attempted where the nurse has not received adequate training in their use.
It is time to move on from the often predominant culture within mental health nursing of attempting to pick up interventions from reading books or handouts.
Mental health nurses should value their practice and insist that the delivery of evidence-based counselling is dependent on the receipt of suitable training in both evidence-based specific and non-specific interventions.