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A cognitive sketch pad to record thoughts of psychiatric patients

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VOL: 101, ISSUE: 09, PAGE NO: 34

Bill Lemmer, PhD, BA, RN, is professor of mental health and learning disabilities, Faculty of Health, Canterbury Christ Church University College

A sketch pad is a collection of words that psychiatric patients use to name their thoughts. Mental health problems cause difficulties in thinking and a sketch pad was devised as an intervention to re-engage patients who are acutely ill and on a downward spiral. By agreement with the patient, the named or primary nurse asks what is most troubling, spacing the words on paper to reflect words that depict distressing, and less troubling, thoughts.

A sketch pad is a collection of words that psychiatric patients use to name their thoughts. Mental health problems cause difficulties in thinking and a sketch pad was devised as an intervention to re-engage patients who are acutely ill and on a downward spiral. By agreement with the patient, the named or primary nurse asks what is most troubling, spacing the words on paper to reflect words that depict distressing, and less troubling, thoughts.

Clinical development
For decades nurses have found it difficult to find a way to engage with mentally isolated patients (Dodds and Bowles, 2000; McKeown et al, 1998; SCMH, 1997).

In cases where engaging with a patient was difficult, if not impossible, it was necessary to find out how to:

- Form a therapeutic alliance and a personal relationship;

- Predict what would be least stressful for patients;

- Provide a way to involve patients in nursing care.

Using a sketch pad in practice
A structured approach to interview patients and record their thoughts was devised. This thought record needed revision each week, with at least three sessions and, if possible, up to five. It needed to be revised on every occasion until all patients were satisfied that the names of their thoughts represented their unique pattern of thinking at that time. The questions were put simply, for example: 'What words do you use to describe your most distressing thoughts?' After writing down what is most troubling, it is then important for the nurse to ask what the opposite is, that is: 'What are you thinking, feeling, or doing when you're least troubled?'

By asking where the patient wants to place a name on the sketch pad, the nurse is asking the patient to focus on that name. The sketch pad is intended to show which thoughts or feelings are most troubling (on the right) and which are less troubling or more satisfying (on the left).

This process allows an increased awareness of troubling thoughts and can help the nurse and patient to better manage them, especially when the negative thoughts are seen in relation to less troubling thoughts. The patient can be helped to reframe thinking.

Clinical examples
In Fig 1 there is a horizontal 'line' of thoughts running from 'Enjoy being at home' on the left to 'Intrusion at night' on the right. Down the vertical 'line' in Fig 1 you have 'Bursting into tears' on top and 'Peace of mind' at the bottom. For the best results in engaging with a patient, allowing both patient and nurse to feel less stressed in moving away from troubling thoughts and thinking of nursing goals, the author found it was best to arrange the names of thoughts across the page from least troubling on the left to most troubling on the right and on a vertical line up and down the page from 'most emotive' at the top to 'least emotive' at the bottom.

In Fig 2 these opposites become slightly clearer, with 'Diversity of interests' running across to 'Totally undistracted' and then at the top of the sketch pad 'My name is in ruins' down to 'Having self-respect and the respect of others'.

When the names of thoughts and feelings are mapped onto the sketch pads (Figs 1-2) and the nurse has a 'mental picture', she or he can conclude each session by asking patients to rate the most troubling thought(s), by asking, for example: 'At the right-hand edge of the picture is your most troubling thought ('Intrusion at night' in Fig 1). I'm going to draw under this most troubling thought a line with the number 10 at one end. This 10 represents intense distress and the number 0 at the left-hand end of this line means the thought is not troubling at all. So where along this scale would you mark your most troubling thought?'

Then the nurse should apply this scale to the least troubling thought on the left-hand side of the sketch pad, to demonstrate effectively the potential for both nurse and patient to focus on the less stressful thoughts. Then the nurse could ask, for example: 'Now let's take the most troubling thought, which you rated as a 10, and apply it to when you are engaged in the activity which you've named as a least troubling thoughts, that is 'Enjoy being at home' (Fig 1) on the left-hand side. How troubled by that negative thought would you be on the zero to 10 scale when you are enjoying being at home?'

The rating scales will:

- Verify the extent of difference between terrible thoughts and less intrusive ones;

- Illustrate to patients a way of framing their thoughts to regain equilibrium;

- Point the way to care planning.

The ratings on the left are always lower whereas on the right they are higher. The scales provide a simple measure to demonstrate there is capacity in the person for cognitive growth and purposeful activity, which can be achieved despite disabling thoughts. That the most troubling and distressing thoughts, feelings or behaviours can be diminished suggests there are resources within the person to manage mental health problems.

Underpinning theory
The sketch pad is derived from work on:

- Thought recording (Greenberger and Padesky, 1995);

- Vulnerability-stress model (Andrews and Jenkins, 1999);

- Problem solving (De Bono, 1991);

- Mind mapping (Buzan, 1993);

- Personal construct theory (Neimeyer, 1993; Walker et al, 1996; Bannister and Fransella, 1986).

Conclusion
The sketch pad was developed to overcome barriers to clinical engagement. It is a method of clinical investigation, a technique for teaching and learning and a way to form partnerships in care planning. Thought recording enables a rapid transfer from disabled thinking to healthy ways forward, for example 'Doing for myself' (Fig 1) and 'Socialising' (Fig 2). Some difficulties with the process that have been discovered include:

- It requires trial and error;

- There is a risk of over-involvement;

- It demands support from colleagues;

- There is a risk of challenging patients' core beliefs;

- It needs time for careful planning.

Success with the sketch pad depends on accepting that each person differs in the way she or he sees situations, and that depends on her or his own perspective. - This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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