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Discussion

Cognitive Beh Therapy

Hello,

I am a home health nurse and my agency likes to send pts with psych illnesses to me because I have a Bachelors in Psychology. I used to work as a tech at a private hospital, but that has been quite some time ago.

I have a new pt who is diagnosed with depression and anxiety. The doctor has ordered visits for CBT. I know I wll need to have homework assignments for the pt. I am looking for some ideas. Please enlighten me.

I know that CBT is about allowing a pt to see that their thoughts control their feelings. I know part of the focus will also be on irrational thoughts and on the here and now.

I remember two things from the groups I used to do:

1. Does it really matter?

2. And is there anything I can do about it?

Thank you.

:)

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    A workbook (it's CBT) I used with patients a few years ago is:

    Thoughts & Feelings: Taking Control of Your Moods and Your Life By Matthew McKay, Martha Davis, Patrick Fanning

    There's also a Cognitive Behavioral Therapy for Dummies book. Really. That should give you a broad overview.

    I question whether doing therapy is within your scope of practice as an RN though. Is it?

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    • Expert

    I'm not sure I'm understanding your question. Are you saying that you're expected, as a home health nurse, to provide cognitive behavioral therapy for this client? Psychotherapy is outside the scope of practice of a generalist RN, and requires graduate education in psychiatric nursing and advanced practice certification. I also have never run into a situation where someone with a BA in psychology was considered qualified/credentialed to function as a psychotherapist. That also requires graduate education in psychology.

    Who is this physician who has "ordered visits for CBT"? A psychiatrist? If not, what business does s/he have ordering any particular modality of psychotherapy for anyone? And a psychiatrist would/should know that a generalist RN is not educated or qualified to conduct psychotherapy. If it's a psychiatrist doing the ordering, does that person realize that a generalist RN is going to be carrying out the order, not a credentialed therapist?

    I, personally, would not touch this situation with a ten-foot pole if I were you. IMO, it's an inappropriate expectation/assignment unless you have further education and credentials that you didn't mention in your post. If this agency wants to be able to offer psychotherapy to home health clients, the agency needs to take steps to have qualified, licensed, credentialed psychotherapists available. This is going to come back to bite somebody if it continues -- I hope it won't be you.

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    I agree with Elkpark. I could do CBT because I'm a certified Adult Psychiatric Clinical Nurse Specialist and trained to do it. If you have the credentials and just haven't mentioned them that's one thing. If you don't, it's another. Also, is providing psychotherapy within your job description even if you do have the credentials? Is it in writing that RNs do psychotherapy? You must never ever do things beyond your job description no matter what you're able to do, or your agency will not back you up if something goes wrong. The board of nursing of your state could take your license too.

    Consider if you were a social worker and you gave the patient medications. It's really a pretty similar thing.

    Check into this more. Talk to your manager. Read the scope of practice for nurses in your state.

    I bet you a nickel or more the doctor assumed someone who does CBT would go do it with the patient, not that you would. If he thought you or another RN would, he doesn't understand what's possible. Did he order nurse visits for CBT or just visits? Did he mean a therapist? Does your agency have the possibility of sending a psychotherapist in the same way they'd send a physical therapist?

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    • Author

    I bet you a nickel or more the doctor assumed someone who does CBT would go do it with the patient, not that you would. If he thought you or another RN would, he doesn't understand what's possible. Did he order nurse visits for CBT or just visits? Did he mean a therapist? Does your agency have the possibility of sending a psychotherapist in the same way they'd send a physical therapist?

    He actually ordered nurse visits for CBT. We do have a MSW.

    This is a strange situation. I must agree.

    I do know that at psych hospitals techs often do CBT groups and sometimes nurses who have no certification,etc. do as well.

    I will do tomorrows visit, but it will be a "normal" visit. I will also call my DON and look at the Nurse Practice Act.

    Thank you.

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    • Expert

    I'm still curious about whether this is a psychiatrist who is doing the ordering, or who??? Physicians frequently ask nurses to do things that are outside our scope of practice -- it's the nurse's responsibility, in those situations, to set the limit and say no.

    I've worked in inpatient psych for many years, in a few different states, and have never seen a situation where techs or staff nurses did actual process/psychotherapy groups -- they do lots of other kinds of groups; skills, educational, goals, etc., but those are structured and v. limited in scope and there is lots of supervision of the techs and staff nurses who lead those groups. That's v. different from doing actual process/therapy-type groups. You may be referring to an educational/skills type group that incorporates some elements and principles of CBT, but that is v. different from doing actual cognitive-behavioral psychotherapy with an individual. (Does this client even want therapy?)

    I encourage you to be v. clear with your agency and this physician about what it is being asked of you, and to clarify with your BON what is and isn't appropriate for you to be doing. This sounds like a bad situation to me.

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    I am a travel nurse in psychiatry and currently working in NYC. We do supportive psychotherapy on the unit and every day we offer groups on DBT.

    http://www.truerecovery.org/learning-center/dbt-dialectical-behavior-therapy

    I posted some information and certainly you can feel free to google this as well.

    I have also worked in State Facilities AND although we did not do DBT groups we did lead groups in other topics.

    I certainly think it is the role of a nurse to be able to lead groups and teach our patients skills that will help them regulate their affect and lead a successful life.

    But we can only give what we ourselves own as well :)

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