Schizophrenia is marked by significant disruptions in thought processes, behaviour and affect. The problems of people with schizophrenia are characteristically complex and heterogeneous (Bellack & Mueser, 1994). In addition to positive symptoms (delusions, hallucinations and interference with thinking) and negative symptoms (apathy, lack of drive, slowness and social withdrawal), most clients with the illness experience depression, suicidal thoughts, self-care deficits and social impairment (Gelder et al., 1996). Many clients have a long duration of illness and continue to experience psychotic symptoms and beliefs despite neuroleptic medication. As a result, re-admissions are frequent. Improving care outcomes for clients with schizophrenia is therefore a challenge for mental health nurses (Chan et al., 2000).
Over the past decade there has been an increasing amount of literature suggesting that cognitive behavioural therapy (CBT) has positive effects in reducing psychotic symptoms, particularly in situations where these are resistant to other forms of treatment (Jones et al., 1998; Haddock et al., 1998). CBT could be one of the treatments of choice for people suffering from schizophrenia. Mental health nurses, who provide 24-h services for clients, are in a key position to use cognitive behavioural techniques to help clients to deal with their symptoms.
However, the application of CBT to clients with schizophrenia in Hong Kong is limited to a small number of mental health workers, as many do not have formal training in CBT. This paper will give an overview of the techniques and research findings related to the application of CBT in the management of clients with schizophrenia. A nursing care plan is used to illustrate the application of the techniques. Issues related to their application in mental health nursing practice will be discussed.

CBT is a structured, problem-orientated approach to the management of people with mental and psychological problems (Stuart, 1998; Kingdon & Turkington, 1998). The A-B-C model is the basic concept of CBT, in which an activating event A leads to emotional or behavioural consequences at C, the consequences being mediated by beliefs at B (Tower et al., 1988). Through the A-B-C model, the activating event, the belief, and the emotional and behavioural consequences for the client, are assessed (Levendusky et al., 1998) (Fig. 1). With clients with schizophrenia, the goal of CBT is to help them to identify the antecedents of the symptoms, and identify and modify dysfunctional beliefs, thoughts and assumptions about the symptoms, with the aim of changing their emotional and behavioural responses to the symptoms in order to cope more effectively.

Many authors have reported that CBT is effective in helping clients suffering from psychotic conditions, such as schizophrenia. For example, Turnbull (1996) maintained that CBT was effective in helping those with persistent delusions and hallucinations. Kingdon & Turkington (1998) and Jones et al. (1998) also stated that the long-term outcome of using CBT in clients with schizophrenia appeared promising, especially when clients were managed from early onset or first episode.
To gain an understanding of the clinical effectiveness of CBT, a literature search was conducted using the database MEDLINE and CINAHL with the keywords `cognitive behavioural therapy' and `schizophrenia'. Eleven studies related to the application of CBT in the treatment of psychotic symptoms were reviewed, of which six were randomized controlled trials (RCTs), three were pre-and post-intervention controlled trials and two were single case studies. Details of the studies are outlined in Table 1.
The duration of application of CBT in these studies ranged from 6 to 76 weeks. Different CBT techniques were used, including reattribution, belief modification, rational thinking strategies, relaxation and anxiety management, social skills training, homework assignment, coping strategies enhancement, problem solving, belief modification, focusing therapy, distraction and cognitive restructuring.
The primary outcome measure in these studies was psychotic symptoms. Other outcome measures varied among studies and included global functioning, anxiety, depression, relapse rate and drug compliance. Despite different outcome measures being used, there was a consistent finding that psychotic symptoms were reduced using cognitive behavioural interventions.
Although studies showed positive results, they have to be interpreted with caution. In some, the number of subjects was small, and in the two case studies only one subject was involved. It would be impossible to generalize the results of these studies. Furthermore, only six out of the 11 were RCTs, which further limits the ability for generalization. Moreover, these studies used different cognitive behavioural techniques in their interventions and there was no attempt to study the clinical effectiveness of a particular cognitive behavioural technique. There was also little information regarding which technique was more effective than others. Therefore, it is difficult to compare the results of these studies.
However, when the review of these 11 studies was compared with other systematic reviews, there were some consistent findings. A systematic review of four RCTs performed by a Cochrane Centre Review Group on the use of CBT with clients suffering from schizophrenia concluded that CBT could be recommended for use and it was effective in improving overall mental state and global functioning. CBT appeared to be a superior intervention to standard care (Jones et al., 1998). The Joanna Briggs Institute for Evidence-Based Nursing and Midwifery (1999) analyzed 20 RCTs and found strong evidence supporting the effectiveness of CBT in improving overall mental state and global functioning of clients with schizophrenia (Hodgkinson et al., 1999). It appears that evidence consistently supports CBT's effectiveness in helping clients with schizophrenia.
As mentioned earlier, different studies used different cognitive behavioural techniques and so it was difficult to compare the results. In practice, because of individual needs and differences, it might be difficult to have one consistent approach in dealing with psychotic symptoms. Hodgkinson et al. (2000) concurred that it was difficult to generate a discrete definition of the treatment modality. To provide guidelines for therapy, they interpreted CBT as an intervention that involved clients establishing links between their thoughts, feelings and actions with respect to the target symptom and the correction of misperceptions, irrational beliefs and reasoning biases related to the target symptoms. They also stated that a further component of CBT should involve either or both of the following interventions: clients monitoring their own thoughts, feelings and behaviours with respect to the target symptoms and promotion of alternative ways of coping with the target symptom.
Conventionally, pharmacological treatment is the treatment of choice for psychotic symptoms. The Joanna Briggs Institute for Evidence-Based Nursing and Midwifery (1999) maintained that pharmacological treatment can help to control psychotic symptoms but it does not provide important coping skills for the disease. These skills have to be provided through forms of psychotherapy. Furthermore, evidence showed that about 5-25% of clients who were on medication continued to experience symptoms. It appeared that these clients needed help from other therapies.

Mental health nurses play a key role in the rehabilitation of clients, and an important role is to provide individual, group and family psychotherapy. In a study in the United States of America (USA), 73% of psychiatric clinical nurse specialists indicated that they use individual psychotherapy and spend 35% of their practice time in this modality. They also claimed that the underlying theoretical framework for therapy is based on cognitive behaviour theory (Betrus & Hoffman, 1992). Because of direct client contact, mental health nurses are in the best position to assess, confront and manage distressing psychotic symptoms and associated problems of clients with schizophrenia and, with appropriate training, to use CBT to help clients to manage their illness.
Studies in the United Kingdom (UK) and the USA have demonstrated that the use of cognitive behavioural techniques by nurses is effective in reducing clients' problems associated with schizophrenia, with reduced psychotic symptoms and better coping abilities in general (Gaedner & Thompson, 1992; Hafner et al., 1996; Jensen & Kane, 1996; Lam, 1997; Sullivan & Rogers, 1997; Lam & Cheng, 1998). They have demonstrated that nurses can be competent CBT therapists.
CBT conducted by nurses appeared to be cost-effective. Baradell (1994) found that care provided by nurse psychotherapists could enhance the cost-effectiveness of services and produce better clinical outcomes. A cost-benefit study conducted by Ginsberg & Marks (1977) also found that clients used fewer health care resources when they were treated by nurses, resulting in significant savings. However, Ginsberg and Marks' study did not include clients with psychoses.
As studies have shown that mental health nurses can be effective therapists in the application of CBT, this could be more aggressively integrated into their role. Freeman & Yates (1998) and Shires & Tappan (1992) supported CBT as an area of advanced nursing practice in psychiatric nursing, and the Joanna Briggs Institute of Evidence-Based Nursing and Midwifery (1999) concurred that nurses are appropriate persons to implement CBT. Thus, there is a need for nurses to develop psychotherapeutic skills in their own area of practice.
Furthermore, the focus of mental health services in Hong Kong is now shifting from hospital to community care. Brooker et al. (1994) suggested that community psychiatric nurses (CPNs) could achieve far more with clients with schizophrenia and their families than previously acknowledged by using psychotherapeutic interventions. CBT is a therapy that CPNs could become increasingly involved in for helping schizophrenic clients with persisting psychotic disturbances. With suitable training they can practice CBT as autonomous therapists. The principles of CBT can also be integrated into nursing care. The following is an example of a nursing care plan illustrating the application of CBT in the care of a client with psychotic symptoms.

This is a brief profile of the patient, Mr Ming Wong (fictitious). This was the first psychiatric admission and first psychiatric contact for Mr Wong, a 20-year-old unemployed, single male. He was admitted to the hospital with the chief complaint that `the police is out to get me'. He stated that he had been sick since he started work as a clerk 4 months earlier after he finished his secondary schooling. Shortly after arriving at the company he began to feel suspicious of other people (particularly his colleagues) and became convinced that the drinking water in the company was poisoned. He was also worried that people were trying to harm him as well as his parents, became withdrawn socially and had poor work performance. Ming told his mother how dangerous he felt things were at work and expressed concerns about his own as well as his parents' safety. He refused to return to work and stayed at home all the time, but his fears continued. Ming came to the hospital at his mother's insistence after she discovered that he was collecting knives and scissors and staying up all night to sharpen them, as he put it, to protect himself when the police came to get him. Before admission he had not slept for 2 days. He did not want to have a psychiatric consultation. He was admitted to the psychiatric hospital through an Accident and Emergency Department by compulsory admission under the Mental Health Ordinance, which is similar to the Mental Health Act in the UK.
At the time of admission, Ming was very suspicious of the staff and other clients on the ward. During the initial interview with his primary nurse, he constantly shifted his eyes around the room and appeared to talk to someone next to him (although no one was there). He told his nurse that he was sure the police were putting thoughts in his head and that the radio had sent him a message to be careful about putting any food in his mouth, warning him that his food was poisoned.
Ming's main problems included auditory hallucination and paranoid delusions. He was very anxious about the hospital environment and had difficulties in relating to others. He also had difficulties in falling asleep at night. Ming was diagnosed as having schizophrenia and was prescribed Largactil 100 mg three times a day.
After being assessed by Keith, Ming's primary nurse, nursing diagnoses were formulated for him. One of these was `altered thought processes evidenced by hallucinations, delusions, exaggerated responses related to inability to process and synthesize information, inability to evaluate reality'. The interventions related to this diagnosis are presented in the nursing care plan in Table 2.

In Table 2, many of the nursing interventions (indicated by asterisks) that are directed at reducing patient's psychotic features are based on cognitive behavioural techniques, such as rational responding, distraction, belief modification, reality testing and activity scheduling. These techniques are suggested to be effective in reducing the frequency, duration and distress associated with hallucinations or to increase control over them (Fowler et al., 1995; Haddock et al., 1993). The following will briefly explain the application of each technique.
Rational responding involves helping the client to accurately identify the content of their voices, and associated cognition, and to generate alternative cognitive responses. Diaries were used to identify voice and thought content and to prompt Ming to generate rational responses (Kingdon & Turkington, 1991; Kingdon et al., 1994; Reily, 1998). He was asked to keep a diary describing the voice and thought content that was upsetting him, and his behavioural as well as affective responses to the thoughts and voices. He was then taught by Keith to generate an alternative response to his psychotic symptoms, such as ignoring the voice or engaging in activities.
A thought-stopping technique was used in which the client could picture a stop sign or imagine a bell going off to stop the progression of the dysfunctional thought (Stuart, 1998). Distraction techniques, such as listening to music, were used to block `subvocalization' that could lead to blocking of the experience of hallucinations (Bentall et al., 1994; Persaud & Marks, 1995; Haddock et al., 1996).
Belief modification comprised modifying Ming's beliefs about his hallucinatory experiences. The rationale behind this is that the key beliefs, or interpretations of the voices, causes the most distress to the person. Modifying those beliefs could reduce the distress associated with them (Kingdon & Turkington, 1991; Bentall et al., 1994; Chadwick & Birchwood, 1994a; Garety et al., 1994; Morrison, 1994; Haddock et al., 1996). Ming was helped to realize that the hallucination that he experienced was not real, as other people did not hear the voices. Milton et al. (1987) suggested that belief modification and reality testing are effective strategies in reducing the conviction associated with delusional beliefs. This involves helping clients to question the evidence underlying their beliefs and to set up behavioural experiments to test the reality of the evidence for their beliefs (Chadwick & Lowe, 1990).
Activity scheduling and detailed planning of activities can help a client to focus on reality as well as provide motivation (Haddock et al., 1998). Ming was helped to identify specific activities which he enjoyed and these activities were arranged for him as far as he could tolerate them. It was important to help him to recognize that progress and recovery from a psychotic episode might be slow, and to build in gradual steps that he could achieve (Hogg, 1996).
Relapse prevention strategies involve assessing the factors or key stressors that contribute to the onset of the psychotic symptoms or even preceding symptoms (Haddock et al., 1998). These include updating advice about cognitive behavioural strategies for psychotic symptoms, developing an individualized plan to manage episodes of psychotic relapse, and developing strategies to manage social disability in the future (Fowler et al., 1995). Tarrier (1993) developed a highly structured approach - coping strategy enhancement (CSE) - as a method of teaching clients to improve their coping processes to reduce positive symptoms and the negative emotions that resulted. Studies show that clients who receive CSE have improvement of delusions, hallucinations and anxiety levels (Tarrier et al., 1993; Drury et al., 1996; Kuipers et al., 1997; Tarrier et al., 1998). CSE involves a detailed assessment of the presence of symptoms, then working with the client to develop a highly individualized coping strategy for each psychotic symptom reported as distressing (Tarrier et al., 1998).

At the very beginning, Ming was unwilling to talk to Keith and would have liked to be left alone. It was only after nurses' continuous demonstration of care and concern that he began to show some response to them. When Keith asked Ming to describe his problems, he had difficulties in verbalizing his thoughts and feelings. However, he did better in his diary, and he was more willing to put down his beliefs and worries in writing. Keith discussed the diary with him, together with ways to handle his hallucinations and delusions. Encouragement and praise were given to Ming by Keith for his improvement, and he developed a trusting relationship with Keith and was more willing to share his feelings with Keith 2 weeks after he was admitted. Ming mentioned that it had been very stressful when he started work a few months ago, and so ways to cope with distress were discussed with him.
Three weeks after admission, Ming felt less anxious about the ward environment and had stopped talking about the food being poisoned. His suspiciousness towards staff and other clients was reduced. He was willing to talk to staff members and began to join in ward activities and talk to other patients. He was able to have 6 hours sleep each night and also participated in ward occupational therapy. Ming demonstrated improved ability to socialize and communicate and also verbalized improved reality orientation. He recognized that the hallucinations that he experienced were not real. Although he still occasionally experienced hallucinations, he was able to distract himself by listening to his personal stereo or engaging in ward activities. He also verbalized that no-one was going to hurt him at work, at home or in the hospital. Ming admitted that he had mental illness and needed treatment.
His medication was reduced on the 4th week to 100 mg twice daily and he appeared to be well maintained. He was discharged at the 6th week of his hospitalization, but before his discharge, education was given to him and his parents regarding his future treatment plan. He was referred to the CPN service and a CPN would continue his treatment plan after he was discharged.
As illustrated by this care study, Ming had made considerable progress. Although this study did not systematically evaluate the implementation of CBT, is seemed to be effective in helping Ming to overcome the psychotic symptoms in a short period of time. It could be argued that the psychotropic drug helped to control the symptoms, as well as the support and care from health care professionals, and that his family contributed to the improvement. However, the use of CBT appeared to be useful in helping him to focus on reality and distract himself from psychotic symptoms, as well as in generating alternative responses to his symptoms. However, follow-up study is necessary to monitor the long-term effects of CBT for Ming.
This case study has also demonstrated that cognitive behavioural techniques can be incorporated into nursing interventions. However, there are some issues that needed to be considered when planning the implementation of CBT.

From the documentation of his progress, Ming appeared to have difficulties in accepting this model of care at the beginning. This might be due to his difficulties in verbalizing his feelings and thoughts to others. Nevertheless, with persistent effort he had established a trusting relationship with his primary nurse and was more willing to disclose his thoughts and feelings to him. The use of distraction, reality testing and activity scheduling appeared to be effective in helping Ming to overcome his problems. However, it is not known whether the majority of clients in Hong Kong would accept CBT. As the majority of the research related to CBT has been conducted in the UK and USA with Caucasian populations, there are few studies related to the application of CBT in Chinese populations.
Some literature suggests that Chinese clients have difficulties in expressing their emotions. The Chinese experience and ways of expressing emotion in general should not be assumed to be the same as those of Western populations. For example, Kuo & Kavanagh (1994) have pointed out that psychological problems are dealt with within the Chinese family as far as possible, mental illness imposing a stigma upon the individuals and their families. In a Chinese culture influenced by Confucian philosophy, self-discipline is regarded as the mainstay of social identity and behaviour, and self-esteem results from the knowledge that one is fulfilling one's social role with grace and dignity and meeting expectations (Kuo & Kavanagh, 1994). A person who has mental illness may perceive failure in meeting their role and consequent loss of face and shame. Any expressions of distress and strong feelings may result in further loss of face, especially if help is sought outside the family or close circle of friends. Consequently, seeking medical help for mental illness is often a last resort. Even during a therapeutic encounter, the person may be withdrawn or remain silent.
Somatization is common in Chinese clients (Chen et al., 1993). Symptoms often reported are insomnia, anorexia, poor memory and concentration, tiredness and dizziness (Kuo & Kavanagh, 1994). Cheng (1993) also commented that Chinese distrust `talking therapy' and have difficulty in expressing emotions. This cultural personality style may lead to difficulties during psychotherapy. Furthermore, it has been suggested in the literature that the Chinese are more likely to expect instructions and specific teachings, rather than to engage in the self-exploration that is the essence of Western psychotherapy. Therefore, it is anticipated that some Chinese clients may not accept this mode of therapy and may feel resistant to the therapist (Cheng, 1993; Lo, 1993).
However, Chen et al. (1993) hold different views on implementing psychotherapy in a Chinese population. In their community survey on the prevalence of mental disorders in Hong Kong, they found that Hong Kong Chinese are willing to talk to health care professionals about their emotional problems if they are given an opportunity to do so. Furthermore, CBT is not just a `talking therapy'; it involves actions such as keeping a diary or planning of activities. CBT may be more acceptable to a Chinese population when compared with other forms of psychotherapy such as psychoanalysis.
Pearson (1999), in her reflections on the personal experience of counseling in Hong Kong and mainland China, reports that Chinese people were willing to share their emotions and feelings when the therapist was open and willing to discuss issues that clients would like to discuss. Pearson (1999) also criticized the literature related to psychotherapy in Chinese culture that tended to focus on homogeneity and assumed that the Chinese are a homogeneous group characterized by collectivism, `familism', fatalism and a concern to preserve `face'. Problems emerge with these crude generalizations.
Hong Kong is a Special Administrative Region of China. However, it was a colony of Britain for nearly 100 years before 1997. This made it a place with combined western and traditional Chinese culture. Hong Kong's unique culture needs to be specially considered when health care professionals are providing care to mentally ill clients. In fact, the value system of Chinese people in Hong Kong may be different to that of people from rural areas in mainland China and Chinese Americans from New York. Pearson (1999) further suggested that the failure of psychotherapy in a Chinese population might be due to the poor technique of the therapist and a lack of understanding of cultural issues related to psychotherapy. She called for rigorous prospective, evaluative studies of the implementation of psychotherapy in the Chinese context.
To integrate CBT into mental health services, account must be taken of clients' cultural values and beliefs. Haddock et al. (1998) suggest that to be effective in using CBT, a detailed description and explanation of various concepts, and the aim and benefits of CBT, should be provided to clients to improve engagement in the treatment session. In Hong Kong there is a lack of research on the use of CBT with mentally ill clients, and culturally sensitive research needs to be conducted to assess the outcome of the therapy and clients' acceptance of it.

At present, CBT is practiced by very few skilled mental health professionals in Hong Kong. Its application in day-to-day clinical practice is restricted by the availability of suitable and skilled therapists. To increase its availability, mental health nurses need to learn the knowledge and skills for using CBT.
There could be two levels of education: pre-registration and post-registration. For pre-registration education, students can gain introductory knowledge of CBT and be able to apply the principles in nursing care. At present, the syllabus for mental health nursing education in Hong Kong consists of only 40 h of theoretical input on general psychology, counselling and psychotherapy. With the small number of hours, it may not be possible to prepare nurses to perform psychotherapeutic skills competently enough to be a psychotherapist. The theoretical input in pre-registration nursing education needs to be strengthened. Students need supervision in order to be able to put theory into practice. Education programmes at the post-registration level should be established to prepare nurses for the role of being a CBT therapist, and this should be an advanced nursing practice role. Programmes such as the Diploma in Problem-Centered Interventions with People with Severe Mental Illness (Thorn Initiative), established in the UK, is an example of a programme that aims to equip nurses with psychotherapeutic skills in taking care of clients with psychotic symptoms (Brooker et al., 1994).
In assuming the role of psychotherapist, mental health nurses must gain autonomy over their practice that frees them from the restrictions of medical hierarchies (Cotroneo et al., 1998). In Hong Kong, health care services are still dominated by medical doctors, and nurses may not be able to function as equal partners in a health care team due to tradition and the level of education that they have received. A great challenge to mental health nursing is to gain recognition from other disciplines that they have the skills, knowledge and competence to practise psychotherapy. There is a need to develop a collaborative model of care based on trust and respect among health care professionals in each others' expertise and to be able to work collaboratively on an equal basis to meet client needs. For mental health nurses, their ability to collaborate with other members of the multidisciplinary team needs to be strengthened by education, demonstrating their competence, and working closely with other disciplines.
It is also very important that nursing interventions are based on valid and reliable evidence. The application of CBT in mental health nursing practice is an underresearched area. With the increasing emphasis on evidence-based practice and clinical effectiveness, local nursing research should be conducted to enrich the body of nursing knowledge related to the implementation of CBT. Some suggested research topics are: nurses' and clients' attitudes to and acceptance of the use of CBT, the influence of Chinese culture on the implementation of CBT, the cost-effectiveness of CBT when compared with conventional treatment, and the clinical outcomes of different CBT techniques in the treatment of clients with psychotic symptoms.

Cognitive behavioural interventions can provide a useful adjunct to traditional treatment for people with schizophrenia. Positive effects have been observed on the mental state of clients after the application of CBT in various studies. CBT could be used by nurses effectively to reduce clients' problems associated with schizophrenia and other psychotic disorders. This could be an area of practice for mental health nurses and CBT could be more aggressively integrated into their role. However, they must receive special training in order to use CBT effectively. Clients' cultural values and beliefs have to be taken into account when implementing CBT, and research needs to be conducted to enrich the body of nursing knowledge related to the implementation of CBT in different cultures.