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Psychiatric-Mental Health Nursing

2.3 Cognitive Theories and Therapies

Psychiatric-Mental Health Nursing2.3 Cognitive Theories and Therapies

Learning Objectives

By the end of this section, you will be able to:

  • Define behavioral and cognitive behavioral theories and therapies
  • Identify nursing application of behavioral and cognitive behavioral theories and therapies

Behavioral theory states that human responses can be retrained. Behavior therapies, in general, provide techniques for people to learn how to control or modify negative behaviors. Primary behavior therapy seeks to change the person’s responses to the environment, usually with reward systems.

Cognitive behavioral theory, one major type of behavioral therapy commonly practiced today, is based on the belief that human thinking drives human behaviors. Cognitive therapy brings behavioral change through identification of negative emotions and reframing the personal script. Examples of this technique include modeling, cognitive, exposure, and acceptance or commitment therapy. The goal for behavioral techniques is to modify or change negative emotions or anger-based behavior associated with identified situations. Cognitive behavioral techniques can assist the person to be more effective at managing or coping with negative emotions (Horiuchi et al., 2018).


The form of psychotherapy that is used to change the way a person feels about or perceives an experience is called cognitive behavioral therapy (CBT). It is effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems, marital conflict, eating disorders, and severe mental illness. CBT helps a person to recognize distorted/negative thinking with the goal of changing thoughts and behaviors to respond to changes in a more positive manner. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. Studies show that CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications (American Psychological Association, 2017).

CBT treatment usually involves efforts to change behavioral patterns. Strategies to achieve these goals might include facing one’s fears instead of avoiding them, using role-play to prepare for potentially problematic interactions with others, and learning to calm one’s mind and relax one’s body. CBT aims to help develop skills to manage feelings in healthy ways. Through in-session exercises and “homework” between sessions, people develop coping skills, whereby they learn ways to change their own thinking and behavior, ultimately changing how they feel. For example, through journaling and reflection on feelings versus behaviors, a client will be developing coping strategies to employ the next time they are exposed to the same situation. CBT clinicians focus on current situations, thought patterns, and behaviors rather than past events. A certain amount of information about one’s history is needed, but the focus is primarily on developing more effective ways of coping with life moving forward.

Essential Elements of Cognitive Behavioral Therapy

CBT is based on the principle that how a person perceives life experiences or interprets events determines how they will feel, behave, or respond. The essential function of CBT is to assist in changing the way a person thinks or perceives an experience to improve the emotion or behavior associated with the event.

CBT has three main core principles, shown in Table 2.5. One principle is that emotional upsets become thoughts that obstruct ways of analyzing situations. A second principle is that emotional upsets are learned behaviors or patterns of thinking. A third principle is that one’s quality of life can be enhanced through better ways of coping with emotions. Treatment with CBT utilizes the influential relationships between these three principles and assists the person to understand their own way of thinking.

Principle Strategy Rationale
Thoughts Learning how to recognize thought-process distortions that are causing emotional upsets, then reevaluating and applying to reality What we think affects how we feel and act.
Behavior Understanding the behaviors and motivations of others in similar situations How we behave affects how we think and feel.
Emotion Learning new coping techniques to apply in difficult situations; application of problem-solving skills to determine which coping technique to use What we feel affects how we think and act.
Table 2.5 Cognitive Behavioral Therapy Strategies (Acha, 2017)

Specific techniques taught to manage one’s thoughts and emotions include mindfulness-based cognitive therapy (MBCT), where behavioral therapy is combined with meditation, and dialectical behavior therapy (DBT), which focuses on problem-solving skills and the ability to find and seek acceptance of negative emotions while tolerating stressors. MBCT has been effective in helping clients cope with anxiety, depression, and bipolar disorders, while DBT has proven effective in helping clients cope with personality disorders, substance misuse, and eating disorders (Good Therapy, 2018).

Psychosocial Considerations

Milieu Therapy

The concept of a therapeutic community is a critical component in mental health care, particularly with behavioral therapy. A therapeutic, controlled, and supportive environment that provides safety and structure while one seeks treatment and works on changing negative behavior is called a milieu. The origin of the word milieu is French for middle place, the safest place in a group, a sanctuary.

Milieu therapy permits health-care clinicians to assess the client while they are exposed to different relationships and behaviors. Allowing clients to function within a milieu community provides a sense of civility, belonging, and accountability. The controlled environment provides consistent routine, which fosters predictability and trust. This allows the client to learn how to respond to stressors through staff and community member feedback and modeled behavior. As described by Belsiyal et al. (2022), the goals of milieu therapy are behavior change through the client’s autonomy and supported decision-making, therapeutic communication directed toward increasing the client’s self-esteem, and overall respect practiced by all participants.

Another CBT-based technique is called acceptance and commitment therapy (ACT), which relies on positive reinforcement (providing a reward for desired behavior, i.e., praise or material incentive) and counterconditioning. Counterconditioning means becoming deconditioned to the negative stimulus. This can be accomplished through brief exposures while being supported until tolerance is built, or by learning a relaxation technique to mitigate the stress of the exposure. ACT has been shown to help people cope with anxiety, stress, psychosis, OCD, substance use, eating disorders, and depression (Glasofer, 2024).

Clinical Safety and Procedures (QSEN)

QSEN Competency: Teamwork and Collaboration

The role of the nurse in caring for clients experiencing emotional stressors is related to primary nursing care, but in collaboration with interprofessional team members. As an interprofessional team member, the nurse may consult with psychiatrists, psychologists, licensed social workers, and other health-care providers. The scope and practice of each team member is clearly defined within their professional licensure.

Nurses play a vital role in behavioral therapy as interprofessional team members modeling and teaching desired behaviors. The nurse, as the coordinator of care, spends the most time observing and interacting with the client. The nurse’s assessment plays a crucial role in understanding and treating the client’s behavior, which allows for a more successful treatment plan.

Behavioral Therapy in Groups

The treatment of several clients together by one or more group facilitators addressing traumatic or stress disorders, depression, learning differences, or other conditions likely to benefit from the interaction is group therapy (Malhotra & Baker, 2022). Group therapy provides opportunities for supportive exchange within the group of individuals who have similar challenges. The professionals who facilitate group therapy may explore emotional, cognitive, and spiritual struggles. Before group therapy begins, the organizer determines group goals, size, duration of meetings, facilitator, and member characteristics. Group therapy can have a fixed life or be ongoing with members leaving and being replaced over time. The group usually has a set of agreed rules, such as the role of members in the group, contribution expected from members, the role of the leader in the group, dealing with inappropriate behavior, etiquette regarding starting and finishing the group as well as when members can leave the room. Group therapy can be in treatment settings or in the community and can take place face-to-face or in virtual sessions.

Group behavioral (and interpersonal) therapy has been proven to be effective in managing substance use disorders, such as addictions, and promoting supportive relationships. Group therapy can be a powerful motivator for change when members are stimulated with new thought processes, develop bonds with other members, and experience adjustments to negative behavior. In group CBT, for instance, the group leader helps group members become aware of negative thought patterns that influence their actions and emotions. CBT groups enable members together to discover ways to refashion their behaviors and interpretations of situations by determining the foundations of their thoughts.

A form of group therapy wherein all the participants of the group are related, as defined by the family members is family behavioral therapy (FBT). FBT can address substance misuse and other addictions, and also assists with managing secondary co-occurring problems within the family unit. Addictions can negatively affect the whole family and can cause secondary problems, such as abuse or conflict, mistreatment of children, and unemployment. In family therapy, the family members try to resolve negative behavior and interactions through learning new coping skills. Then, participants apply these strategies to improve the situation at home.

Cultural Context

Adapted Cultural Formulation Interview for Children and Adolescents

The Cultural Formulation Interview (CFI) is a structured tool in the DSM-5, adaptable to the setting, and used to assess the influence of culture on a client’s experience of distress (Jarvis et al., 2020). The following is an adapted version of the CFI tool for children and adolescents that may be used in family therapy.

  • Suggested introduction to the child or adolescent: We have talked about the concerns of your family. Now I would like to know how you are feeling about being [age] years old.
  • Feelings of age appropriateness in different settings: Do you feel you are like other people your age? In what way? Do you sometimes feel different from other people your age? In what way?
    • If they acknowledge sometimes feeling different: Does this feeling of being different happen more at home, at school, at work, and/or at some other place? Do you feel your family is different from other families? Does your name have special meaning for you? Is there something special about you that you like or are proud of?
  • Age-related stressors and supports: What do you like about being at home? At school? With friends? What don’t you like at home? At school? With friends? Who is there to support you when you feel you need it? At home? At school? Among your friends?
  • Age-related expectations: What do your parents or grandparents expect from a person your age in terms of chores, schoolwork, play, or religion? What do your teachers expect from a person your age? What do other people your age expect from a person your age? (If they have siblings, what do your siblings expect from a person your age?)
  • Transition to adulthood (for adolescents): Are there any important celebrations or events in your community that recognize reaching a certain age or growing up? When is a youth considered ready to become an adult in your family or community? What is good about becoming an adult in your family? In school? In your community? How do you feel about “growing up”? In what ways are your life and responsibilities different from your parents’ life and responsibilities?

(American Psychiatric Association, 2013)

Nursing Applications of Behavioral Therapies

Nurses use behavioral therapy treatments and techniques to help clients alter their maladaptive responses to certain scenarios. Altering these responses can often ameliorate psychological distress and mental health challenges. Nurses can use CBT practices, for instance, to assist clients in lessening psychological distress and in building up coping tools to enhance their mental health. Nurses assess and evaluate, on an ongoing basis, clients with mental health challenges to recognize behavioral changes and developments. As educators, nurses teach clients about the effects of thoughts and feelings on behavior. Nurses are support persons and coaches when clients are in counterconditioning, for example, and can provide honest praise for the client’s accomplishments. Further, nurses facilitate collaborative care when working with therapists and other providers.

In group therapy, nurses can play a vital role in leading or facilitating the group to achieve desired outcomes and providing feedback to group members. In family therapy, nurses can teach the family unit new coping strategies that reduce negative behavior and reinforce adaptation to common stressors. Interventions, such as education related to healthy lifestyle, can be effective for stress reduction and for family unity.


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