Clinician's Guide to Mind Over Mood (11 page)

Persons, J. (1989).
Cognitive therapy in practice: A case formulation approach.
New York: W.W. Norton.

Cognitive Therapy of Depression
(Beck et al., 1979) provided therapists with the first detailed cognitive therapy treatment protocol. Today there are specific cognitive therapy treatment protocols for almost every diagnosis in the Fourth Edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV: APA, 1994). With greater specificity in our clinical methods, we are better able to help many more individuals in brief therapy today than we could 20 years ago. The challenge to therapists is that more knowledge is required to provide state-of-the-art cognitive therapy today than was previously necessary.
Chapters 4
through
7
of this clinician’s guide show you how to use
Mind Over Mood
in ways that are consistent with current cognitive therapy treatment protocols.

Cognitive therapy has been shown in outcome studies to be an effective brief treatment for outpatient depression (Dobson, 1989; Hollon & Najavits, 1988), inpatient depression (Miller, Norman & Keitner, 1989), panic (Salkovskis & Clark, 1991; Sokol, Beck, Greenberg, Wright, & Berchick, 1989), generalized anxiety (Butler, Fennell, Robson & Gelder, 1991), and eating disorders (Garner & Bemis, 1982). In addition, it can be useful for the treatment of diverse problems ranging from relationship difficulties (Beck, 1988; Baucom & Epstein, 1990; Dattilio & Padesky, 1990) to schizophrenia (Kingdon & Turkington, 1994) and heroin addiction (Woody et al., 1984)

Outcome is increasingly measured not only by treatment success but by relapse prevention. In the area of relapse prevention, cognitive therapy appears to emerge as a treatment of choice. Compared with medication and other psychotherapies, cognitive therapy has been shown to have lower relapse rates for depression (Blackburn, Eunson & Bishop, 1986; Evans et al., 1992; Hollon, Shelton, & Loosen, 1991; Shea et al., 1990; Thase, 1994).

Effective cognitive therapy involves building skills. Research has demonstrated that depressed clients are less likely to relapse if they are capable of identifying, testing, and altering their automatic thoughts (Neimeyer and Feixas, 1990).
Mind Over Mood
was written in step-by-step fashion to reflect the learning sequence that most clients follow to acquire the skills linked to lower relapse rates.

Basic skills taught in cognitive therapy can help clients overcome a variety of mood, behavior, and relationship problems.
Mind Over Mood
can be used to structure and guide the treatment of clients with a wide variety of presenting problems. The four clients introduced in
Chapter 1
of the treatment manual and followed through the remainder of the book represent clients with well-defined and discreet diagnoses and clients with multiple problems, clients treated in both inpatient and outpatient settings, clients in both brief and long-term therapy. Clients with whom you work will probably be able to identify with at least one of the four example clients described in the treatment manual.

Research suggests that the effectiveness of cognitive therapy is contingent on the practitioner being faithful to the cognitive model and cognitive therapy principles (Thase, 1994).
Mind Over Mood
was written, in part, to make it easier for you to adhere to the cognitive model, follow the principles that have been demonstrated to be effective, and help you achieve consistent, effective results.

While the fundamental skills we teach in cognitive therapy are similar across client problems, the order and manner in which the skills are taught vary according to client characteristics, diagnosis, therapy setting, and length of treatment available. The remaining chapters of this guide suggest variations in the use of
Mind Over Mood
for different client populations, diagnoses and therapeutic circumstances. Therapists should be familiar with the principles described in
Cognitive Therapy of Depression
(Beck, Rush, Shaw, & Emery, 1979) and with Chapter 10 of
Mind Over Mood
before devising a treatment plan for depressed clients.

We suggest you ask depressed clients to read the Prologue to
Mind Over Mood
first, followed by Chapter 10. Depressed clients should complete the
Mind Over Mood
Depression Inventory (Worksheet 10.1) or some similar brief measure of depression. A depression inventory is a tool with which to gauge the severity of a client’s depression, detail the depression symptoms, and provide a baseline on which to measure improvement. The
Mind Over Mood
Depression Inventory was based in part on symptoms outlined in DSMIV.

Clients can complete the
Mind Over Mood
Depression Inventory regularly and record and monitor their scores on the graph in Worksheet 10.2. This graph provides visible evidence of improvement or lack of improvement, thus indicating whether therapy is helping or needs to be modified in some way. If the client has difficulty graphing depression scores, you can help by completing the graph in session. Clients who are capable can graph their own scores each week after answering the items of the
Mind Over Mood
Depression Inventory. You or your client can duplicate the inventory reprinted in the Appendix of the treatment manual or use the inventory answer sheet in the Appendix to record client answers each week.

After reading Chapter 10 of
Mind Over Mood
and completing the initial depression inventory, the client can read Chapter 1 (Understanding Your Problems). Chapter 1 provides a framework in which clients begin to understand their difficulties and the interventions that will occur in therapy. The problems the client lists on Worksheet 1.1 can be used as a starting point for developing therapy goals.

Clients experiencing moderate to severe depression initially respond more positively to the activity scheduling described in the last half of Chapter 10 of the treatment manual than to the cognitive interventions described in Chapters 4 through 9. If, in your clinical judgment, the client would initially benefit more from behavioral interventions, be certain the client completes Worksheet 10.4 (Weekly Activity Schedule).

After the client completes the Weekly Activity Schedule, you can ask the client the questions on Worksheet 10.5 to guide learning. Most clients discover that they feel less depressed when they are more active, engaged in pleasurable activities, or actually accomplishing something. In the next session, you and the client might use what you learned from Worksheets 10.4 and 10.5 to plan activities the client can do in the following week to decrease depression.

Most depressed clients will need help from a therapist to plan activities. A Weekly Activity Schedule form can be used to write a plan for the upcoming week. However, the client should be encouraged to substitute preferable activities as they occur to him or her. The activity plan made in the therapy session is a backup plan that provides ideas for activities whenever the depressed person is tempted to simply “do nothing” for long periods of time.

While experimenting with activities to improve mood, the client can begin to read Chapters 2 through 7 in
Mind Over Mood
in sequential order. The pace at which the client proceeds through the treatment manual will depend on level of depression, comprehension, and time available to complete the exercises described. Some clients may complete six chapters in the first two or three weeks of therapy. Other clients may require one or more weeks to complete each chapter. Whatever pace a client sets, be certain to discuss what was learned each week and to review completed exercises.

Almost all depressed clients proceed more slowly through Chapter 6 compared with earlier chapters. Learning to look for evidence that contradicts depressive negative thinking is difficult at first. It is not unusual for clients to spend several weeks mastering the skills described in this chapter. If the number of therapy sessions is limited, it may be preferable to meet less often once the client reaches Chapter 6 than to hurry a client in the acquisition of evidence-collecting skills. The key to depression treatment is learning to identify hot depressive thoughts (Chapter 5) and to look for evidence supporting and contradicting hot thoughts (Chapter 6). By the time clients have mastered these skills and the ability to generate alternative or more balanced thoughts (Chapter 7), they have acquired the primary skills necessary to recover from depression.

Chapter 8 (Experiments and Action Plans) of the treatment manual may be used in therapy for depression whenever it seems useful. For example, if a Thought Record (Chapters 4–7) reveals a problem central to the depression (e.g., the negative thought “I’m a bad parent” is supported by evidence and the client consequently sees himself as inadequate), an Action Plan could be used to begin to solve the problem (help this client become a better parent). Also, depressed persons often predict that activities will not be “fun” or “worthwhile” and use these predictions to support inactivity. A portion of Chapter 8 describes how to use experiments to test these types of beliefs. You can either set these experiments up yourself for the client or use the text of Chapter 8 to guide you and the client in this task.

Most depressed people identify with either Marissa or Ben in
Mind Over Mood.
This identification can be used to encourage depressed clients by showing how Marissa and Ben overcome “stuck” points in therapy by developing new skills. Also, clients can see in the Epilogue that Marissa and Ben did not improve in a purely linear way (Figures E.1 and E.2). In fact, you should inform depressed clients that it is normal to experience fluctuations in depression levels throughout treatment.

Most depressed clients who master the skills taught in Chapters 1 through 8 and 10 learn what they need to know to overcome depression and reduce the likelihood that they will face major depression again. These clients do not need to read the remaining chapters of
Mind Over Mood,
although they may wish to read more about anxiety (Chapter 11) or anger, guilt, and shame (Chapter 12) if these emotions are also prevalent in their lives. You may also wish to recommend that depressed clients complete a
Mind Over Mood
Depression Inventory once a month following completion of therapy to detect increases in depression symptoms over the levels at termination of therapy. A score increase of five points or 30% (whichever is greater) could be used as a cue to reread sections of the treatment manual and complete Thought Records for a few weeks to reduce the risk of relapse. It is important to convey to clients that recurrence of depression is not a sign that treatment has failed but a chance to pinpoint areas of continued or new vulnerability and to use the skills learned to resolve the problems. Subsequent depressions will probably be briefer and less severe if clients apply cognitive therapy skills soon after the depressions appear.

Clients who have experienced chronic or lifelong depression need to use the methods described in Chapter 9 (Assumptions and Core Beliefs) of
Mind Over Mood
after mastering the basic skills taught in Chapters 1 through 8 and 10. Most people with histories of chronic depression have developed core assumptions and beliefs (schemas) that maintain mild to moderate levels of depression even when severe depression lifts. Marissa is the case example of this pattern, and some of her core beliefs are described in Chapter 9. In order to break the depression cycle for similar clients, it is necessary to identify the assumptions and schemas associated with their depression. More detail on how to use Chapter 9 to change core assumptions and schemas is given in
Chapter 7
of this guide.

One of the hallmarks of depression is negativity. When they begin therapy, many depressed clients are skeptical that
Mind Over Mood
or any other treatment procedure will be helpful. You will lose credibility with a depressed client if you guarantee that therapy will help. Following is a dialogue that has been helpful with depressed clients.

T:   (
After presenting the treatment manual and describing its proposed use in therapy
) How does this sound to you? Would you be willing to give this book a try?

C:   I don’t know. It seems like a lot of work.

T:   It will involve some work on your part. Of course, if I could guarantee your work would help you feel better forever, I’m sure you’d give a try. But we can’t be sure it will help you. What do you think are the odds it will help?

C:   I doubt it will. I’ve been depressed a long time and nothing helps me.

T:   So what’s the use of putting out the energy to do this if it won’t help, right?

C:   Right.

T:   I’m glad you let me know you are not very hopeful. Fortunately, if this book is going to help you, it will help even if you don’t believe in it. And if it isn’t going to help you, we can find that out in just a few weeks of trying it. What do you think about trying this book for a few weeks? Then, based on your experience with the book, we can talk about whether it seems helpful or you or not. If it’s not helpful, we can stop using it.

C:   Just for two weeks?

T:   How about for three weeks? So you give it a fair try.

C:   OK. I can do that.

A common experience in depression is feeling overwhelmed. Some depressed clients look at
Mind Over Mood
and want to put it aside because it looks like too much to read and understand. They think worksheets and exercises are too complicated or that they themselves are too stupid or too inept to complete them. When these reactions occur, thank clients for letting you know how they are reacting.

T:   When you looked at the Weekly Activity Schedule, your shoulders slumped. What went through your mind?

C:   I just can’t do this. It’s too much.

T:   I’m glad to know that’s how it seems. Let’s see if it is too much. If it is, we can break it into smaller pieces.

C:   Maybe I could do a small bit. The whole page just looks too hard.

T:   Well, let’s try a bit of it together and see how it goes.

C:   OK.

T:   Right now it’s 2:30 on Wednesday. In the 2:00-3:00
P.M.
block, what would you write down to describe what you are doing?

C:   Counseling.

T:   OK. Take this pen and write “Counseling” in that time spot. (
Pauses while client writes.
) Now, how depressed have you been feeling sitting here with me?

C:   On this 100-point scale?

T:   That’s right.

C:   About an 80.

T:   OK. Write “80” next to the word “Counseling.”

(
Therapist and client continue filling out the activity record for earlier hours of the day.
)

T:   Well, you’ve just filled out six hours for today. How long did that take you?

C:   I guess about five minutes.

T:   Does it seem easier or harder now that you’ve done part of it?

C:   Easier. I guess it’s not as hard as I thought.

T:   Could you remember back six hours pretty easily?

C:   Yes.

T:   So maybe you’d need to fill this out only a few times a day. At lunch you could fill it in for the morning, at dinner for the afternoon, and at bedtime for the evening hours.

C:   I suppose I could.

T:   Let’s also talk about how to handle it if you forget to do it one day, or what to do if you get stuck at any point during the week.

As this example shows, depressed clients often feel less overwhelmed when they actually do something than when they think about doing something. It is therefore a good idea to begin all assignments in the therapy session to test beliefs that an assignment will be too difficult. Clients assigned to read a chapter can even practice by reading one paragraph in your office if they are so depressed they think reading will be too difficult.

An additional benefit of beginning therapy assignments in the office is that you can assess whether an assignment is truly too large or difficult for your client. If it is, break it into much smaller pieces or devise a different assignment. If the example client had difficulty remembering activities and rating moods, the therapist might have suggested that the client notice just one time during the week when she felt better and one time when she felt worse and write these down to help her remember them for discussion in the next session.

A third common element in depression is hopelessness. Hopelessness is important to monitor in the treatment of depression because it is a good predictor of suicide. It is critical to reduce hopelessness whenever possible. How do you do this when hopelessness may interfere with client compliance with treatment? One helpful approach is to regularly inquire about hopelessness and acknowledge its credibility to your client. At the same time, it is important to let your client know that you do not find his or her problems hopeless. Further, it can help to provide concrete evidence to your client that expectations of doom do not mean doom is certain. One way to do this is to create hope in response to client negative reactions to
Mind Over Mood
or other aspects of treatment.

T:   I notice you completed Worksheet 1-A (Understanding My Problems). What did you learn by doing this?

C:   I’ve got lots of problems. I may as well give up.

T:   Let’s see. Yes, you do have lots of problems. Would solving even one of these problems help?

C:   No. I’d have to solve them all.

T:   That’s a pretty tough order.

C:   So you agree. It’s hopeless.

T:   Well, if I had to solve them all at once, I’d feel pretty overwhelmed. But I bet if I could solve half of them, the other half would be easier to handle.

C:   Maybe. But how could I solve even half of them?

T:   Well, you’ve got me there. That’s tough. Whenever I look at more than one problem at once, they seem pretty tough to solve.

C:   So you’re saying I have to look at one at a time.

T:   Well, if we look at one of these problems by itself, I bet we can solve it. If we knock them off one at a time, in a while your life would be much better.

C:   How can you fix me getting laid off from my job?

T:   Oh, I’m sure we can somehow fix the problems associated with that if we work on them together. But before getting into the details, let’s decide if that’s the best place to start. First, would you be willing to give my idea a try—to solve one problem at a time?

C:   Yeah. For a bit.

T:   OK. Let’s look at your list here. Why don’t you pick which problem we should solve first? Which one do we need to solve to help you most right now?

The therapist simultaneously acknowledges the client’s hopelessness and provides an alternative viewpoint. By using guided discovery as described in
Chapter 1
of this guide, the therapist helps the client see the advantages of tackling one problem at a time. Making progress in solving one problem will provide more hope to the client than hours of discussion about hope, so it is important to counteract hopelessness with positive problem solving and action. The hopeless client needs to experience some progress and relief from suffering to regain hope. For a thorough discussion of the assessment and treatment of suicidal clients, we recommend
Suicide Risk: Assessment and Response Guidelines
(Fremouw, dePerczel, & Ellis, 1990).

Some depressions are referred to as
melancholic
because they are marked by an almost complete lack of pleasure or responsiveness to positive events. People experiencing this type of depression often have significant physiological symptoms of depression, such as early morning awakening, psychomotor retardation or agitation, and weight loss. These clients can seem as unresponsive to treatment as they are to much of their life experience.

Clients with melancholic depression function at a very low activity level. They may lie in bed or sit in front of the TV for hours with little energy or motivation to do much else. When clients are at such a low level of functioning, therapy should be more behavioral than cognitive. Therapists should focus on the behavioral exercises discussed in Chapter 10 of
Mind Over Mood
and should help energize the depressed client through construction of very small behavioral experiments following the principles outlined in Chapter 8 of the treatment manual. For example, a depressed inpatient who believes “I can’t take a walk or do anything but sit in this chair” might be assisted to test this belief in a series of small-step experiments. First, the patient may be helped to stand and walk a few feet from the chair. Following this experiment, the therapist and patient can discuss its meaning.

T:   You told me you didn’t think you could walk over to the desk. Are you surprised you did it?

P:   Yes.

T:   What are you feeling right now?

P:   Nothing.

T:   Do you think you could do it again?

P:   I suppose so.

T:   I wonder what else you could do if we tried it out?

P:   I don’t know.

As you can see, the client remains fairly nonresponsive. Notice that the therapist keeps her questions and statements brief and simple to increase the likelihood that the patient will understand what is said. The therapist’s questions introduce possibilities that may become meaningful to the client at some point. It is important for the therapist to take a gentle but firm approach in pushing a patient who is this depressed to increase activities in small but meaningful ways. This patient might eventually be encouraged to walk to a day room in the hospital where he will be surrounded by people as he sits.

Melancholic depression, like all severe depressions, is usually treated with a variety of interventions, including medication. When the melancholia lifts, the depressed patient is ready to benefit from cognitive interventions in addition to behavioral experiments.

People who have experienced recurrent depression or who experience a mixture of grief and depression often have difficulty discriminating between depression and grief or sadness. Some clients think that they need to rid themselves of all sad reactions or they will be susceptible to a return bout of depression. It is helpful to tell clients that sadness and grief are normal, healthy emotions that are part of the human experience. These emotions validate our love for people we have lost and help us learn what we value in life.

One way to teach people to discriminate between sadness or grief and depression is to review the cognitive features of depression described in Chapter 10 of the treatment manual. Thoughts such as “I miss him,” “My life is more empty now that she is gone,” “I wish this had never happened” signal sadness or grief because they focus on what has been lost. In contrast, depressed thoughts are self-critical (“It’s all my fault. I’m no good”), negative about the world (“No one cares for me”), and hopeless about the future (“Things will never get better. Nothing will work out for me”). Sadness and depression often feel similar physiologically and emotionally. The content of our thoughts is often the best way to determine if emotional reactions are healthy grieving or potentially self-destructive depression.