Nurse therapists for neurotic and habit disorders

In 1972 Isaac Marks, a psychiatrist working at the Maudsley Hospital, began a 3-year experiment to determine whether nurses could be trained to deliver behavioural interventions for neurotic disorders. Marks recognized that behaviour therapy was becoming the treatment of choice for a range of very handicapping neurotic conditions. However, he also noted that there were insufficient numbers of psychiatrists or psychologists to deliver this treatment. Marks' innovative intention was to train nurses to become autonomous, in the sense of being able to screen and assess referrals, deliver interventions, evaluate outcome, and then discharge the patient back to their referral source. This outcome was what one would normally expect of clinical psychologists or psychiatrists, but certainly not of nurses at that time. He did, however, recognize that these nurse therapists would require a great deal of clinical supervision compared with that given to psychiatrists or psychologists in training. Marks et al.(l5) first reported uncontrolled data from this experiment in 1977. The original training was tested on five nurses, and all patients seen by them (amounting to several hundred) were assessed with multiple measures of change taken before treatment, after treatment, and at various follow-up intervals for 1 year. Marks then tested the efficacy of nursing therapy within the context of a randomized controlled trial and economic analysis in primary care. (16) This study showed very significant differences between nurse therapist intervention and standard general practitioner care on all measures. The economic analysis demonstrated substantial benefits to both the patient and the health-care system.

The nurse therapy training model has continued to be used in the United Kingdom, but as an 18-month full-time programme—essentially a clinical apprenticeship. Trainees focus on acquiring skills in behavioural and cognitive approaches for a number of core conditions:

• agoraphobia and panic disorders

• simple and social phobias

• obsessive-compulsive disorder

• sexual problems

• habit disorders (e.g. tics, enuresis, stammering, etc.)

• a miscellaneous group of conditions, including body image disorder, Tourette's syndrome, and chronic fatigue syndrome.

Much of the initial training utilizes video-feedback techniques, and trainees are taught to use batteries of valid and reliable outcome measures, as well as acquiring skills in functional analysis, behavioural avoidance tests, etc. Trainee nurse therapists have to treat a minimum number of patients in each of the above categories of disorders. They are expected to demonstrate expertise in a full range of behavioural interventions applied in various treatment settings, ranging from inpatient units to the patient's own home. The first 12 months of training is rigorously supervised by full-time trainers. However, in the final 6 months prior to qualification, trainees are sent to areas away from the training centre and work in conditions approximating those of everyday clinical practice. In the United Kingdom, nurse therapists can register as psychotherapists and can be employed in clinical posts equivalent to those normally occupied by clinical psychologists. Health insurance companies reimburse nurse therapy fees in the small, but not insignificant, United Kingdom private health-care sector.

All nurse therapists trained since 1972 have been followed up in three studies. (1 18 and ^ Although these are questionnaire follow-ups, with no actual observation of clinical practice, the results do provide considerable encouragement. The majority of nurses trained in the various courses continue in clinical practice for many years, and most report devoting most of their clinical time to working with the core categories described above, using the interventions in which they were trained. They also report that they continue to apply valid and reliable measures of change in their work. Although the economic benefits demonstrated by Marks are clear, the problem with this programme is that training is very labour intensive, and therefore expensive. At present, there are probably only 200 whole-time-equivalent nurse therapists in the United Kingdom, each treating approximately 60 patients annually, (18> making a total of approximately 12 000 patients a year. Given that the point prevalence for panic disorder with agoraphobia is approximately 300 000 of the United Kingdom population, (29 this significant nurse training endeavour has yet to make a major impact. Some further discussion of this programme will follow in the concluding section of this chapter.

Duggan et al/21,' evaluated the work of nurse therapists in a very large audit of 2000 cases, and other randomized controlled trials involving nurse therapist-provided interventions have shown very positive outcomes in chronic fatigue syndrome,(22) agoraphobia/23,24 and post-traumatic stress disorder/25)

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