Clinician's Guide to Mind Over Mood (12 page)

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Cognitive therapy of depression.
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Cognitive therapy of depression and anxiety.
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Cognitive therapy of suicidal behavior.
New York: Springer.

Freemouw, W., de Perczel, M., & Ellis, T. (1990).
Suicide Risk: Assessment and response guidelines.
New York: Pergammon Press.

Gilbert, P. (1994).
Depression: The evolution of powerlessness.
London: LEA.

Scott, J. (1992). Chronic depression: Can cognitive therapy succeed when other treatments fail?
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The psychological treatment of depression: A general guide to the theory and practice of cognitive behaviour therapy.
London: Routledge.

A
specialized cognitive therapy treatment protocol has been designed for each of the anxiety disorders. Therapists have the greatest success in treating anxiety disorders by applying differential treatment approaches to the different types of anxiety. Beck, Emery, and Greenberg (1985) provide a good overview of the cognitive theory of anxiety and a variety of the treatment methods used. More detailed treatment protocols for specific anxiety disorders are provided in Hawton, Salkovskis, Kirk, and Clark (1989). In the following sections, we offer brief guidelines for treating anxiety disorders.

Regardless of the type(s) of anxiety experienced, clients can begin therapy by reading the Prologue of
Mind Over Mood
and then Chapter 11 (Understanding Anxiety). Ask clients to complete the
Mind Over Mood
Anxiety Inventory (Worksheet 11.1) and mark the score on Worksheet 11.2. Clients can complete the anxiety inventory (which assesses the presence of common anxiety symptoms described in DSM-IV) on a weekly basis and record the scores on Worksheet 11.2.

By charting weekly anxiety scores on Worksheet 11.2, clients can observe increases and decreases in anxiety as therapy proceeds. Observing the pattern of change in anxiety scores helps determine when to continue or change the treatment plan. Of course many treatment steps may lead to a temporary increase in anxiety; weekly fluctuations in scores are not as significant as trends sustained over several weeks or more.

For all anxiety disorders it is important that assessment of hot thoughts (
Mind Over Mood,
Chapter 5) includes looking for images. The majority of people who experience anxiety have images when most anxious. Images can be traumatic flashbacks (posttraumatic stress), images of specific feared catastrophic disasters (phobias, generalized anxiety disorder), or repetitive images of violence or sexual acting out (obsessive-compulsive disorder).

After reading the Prologue and Chapter 11, clients with generalized anxiety disorder (GAD) can read the rest of
Mind Over Mood
in the sequence written. Some clients may find it useful to complete a Weekly Activity Schedule
(Mind Over Mood,
worksheets 10.4 and 10.5) for one week after reading Chapter 1. In Chapter 10, activity scheduling is described as a stage in depression treatment, but this same worksheet can help therapist and anxious client pinpoint situations or times of the week that particularly trigger anxiety. For example, one client discovered she became most anxious when she had more than one task to do at a time. She later learned to link her anxiety with perfectionistic beliefs. Anxiety triggers can be a focus of intervention in applying skills learned throughout the manual.

Tracking anxious automatic thoughts (
Mind Over Mood,
Chapter 5) helps the person with GAD identify anxious images and “what if?” catastrophic fears. Two types of thinking sustain GAD: overestimations of danger and underestimation of coping ability. Clients can reduce GAD by completing Thought Records (Chapters 5–7): Weighing the evidence diffuses catastrophic certainty, often decreases estimations of danger and increases estimates of coping ability. Chapter 8 is particularly helpful in transforming “what if?” thinking into “then what?” thinking, an important step in increasing clients’ confidence in their coping abilities. Chapter 8 can be used to help GAD clients develop coping plans (Action Plans) for each of the foreseen potential disasters. Finally, clients with long-term GAD often have sustaining core beliefs and can benefit from the interventions described in Chapter 9.

A very specific and highly successful treatment protocol for panic disorder has been developed by Clark (1989). This treatment approach is effective with 80% to 95% of clients within 5 to 20 sessions with less than 10% relapse after one year’s follow-up (Clark et al., 1994). A similar treatment has been developed by Barlow (1988). For a more detailed explanation of the cognitive treatment of panic disorder, see Clark (1989).

Multiple lines of research support the cognitive theory of panic, which states that panic disorder results from the catastrophic misinterpretation of internal sensations (physical or mental). People who panic enter a vicious cycle in which sensations are followed by catastrophic beliefs that lead to anxiety and therefore more sensations, as shown in
Figure 5.1
. Further, people with panic disorder usually avoid activities or experiences associated with feared sensations. For example, a woman who believed a rapid heart rate signaled an oncoming heart attack avoided walking up stairs because this exercise caused her heart rate to increase.

Figure 5.1
.
Vicious circle in panic disorder.

Cognitive therapy of panic disorder involves (1) identifying the catastrophic fears (hot thoughts) linked to sensations (
Mind Over Mood
Chapter 5), (2) inducing sensations to demonstrate the vicious cycle, test catastrophic fears, and identify alternative noncatastrophic explanations for sensations (Chapter 6–8), (3) ongoing behavioral experiments to see whether the catastrophic or noncatastrophic explanations provide a better understanding of the occurrence of sensations (Chapter 8), and (4) behavioral experiments to decrease avoidance behaviors so that clients can discover that feared catastrophes won’t happen even under the worst of circumstances (Chapter 8).

To illustrate point 4, one man avoided becoming overheated because he feared that sweating indicated an oncoming heart attack. He did experiments in which he allowed himself to become overheated: He wore sweaters and an overcoat in a warm room to induce sweating beyond normal experience. His catastrophic fear dissipated when he discovered that intense sweating did not bring on a heart attack. In
Mind Over Mood,
Linda is the example client with panic disorder. Chapter 8 of the treatment manual includes a description of the behavioral experiment procedures Linda followed in her therapy to test her catastrophic fears and reduce avoidance behaviors.

A common therapist error is using cognitive therapy for panic disorder with clients who experience panic attacks but do not have panic disorder. Clients with any type of severe anxiety can experience panic attacks. The panic treatment described here should be applied only when panic attacks are not symptomatic of another anxiety diagnosis; that is, when at least some panic attacks occur “spontaneously” rather than in response to a feared situation.

Because the treatment of panic disorder is very specific clients who are in treatment for panic disorder alone need to read only a few chapters of Mind
Over Mood.
A brief case description illustrates this abbreviated treatment model.

In session 1, the therapist assesses Roger, a 46-year-old welder, and determines that he meets criteria for panic disorder. The therapist asks Roger to read the Prologue and Chapter 11 of
Mind Over Mood
and to complete the
Mind Over Mood
Anxiety Inventory before the next session.

In session 2, the therapist interviews Roger about a severe panic attack he had the previous week, using the questions that help identify hot thoughts in the Helpful Hints box on page 51. The questioning follows that suggested by Clark (1989) and quickly pinpoints the catastrophic fear related to sensations.

By the end of the second session, Roger has a clearer idea of the link between his physical sensations, his catastrophic thoughts about these sensations (“I’m having a heart attack,” an image of lying dead on the floor), and panic. The therapist suggests that Roger read Chapters 5 and 6 of
Mind Over Mood,
paying particular attention to how Linda in Chapter 6 looks for evidence to support her fear that she is having a heart attack.

In session 3, Roger and his therapist induce the sensations that frighten Roger to look for alternative explanations for them. (Note: All clients presenting with symptoms of anxiety should have a medical clearance that rules out physical illness. Roger had been examined by his general physician and a cardiologist, neither of whom found evidence of a heart problem.) Sensations are induced by running in place, hyperventilating, and imagining his most recent panic attack. These inductions (chosen for their similarity to Roger’s panic experiences) lead Roger to conclude that exercise, changes in breathing, and anxious mental imagery can all bring on the sensations he assumed were indicators of a heart attack.

By the end of this session, Roger is only 50% certain that breathlessness, a racing heart, sweating, and lightheadedness are dangerous. The therapist asks Roger to read Chapter 7 of
Mind Over Mood
and compare his experiences in the third session with Linda’s panic experiences as described in the manual. During the coming week Roger also tries to discover alternative, noncatastrophic explanations for troubling sensations that occur.

In session 4, Roger and his therapist continue to induce sensations and discuss noncatastrophic explanations for sensations that occurred “spontaneously” during the week. Roger reports a steady decline in his scores on the
Mind Over Mood
Anxiety Inventory and a decrease in panic attacks from daily to only two times in the preceding week. The therapist helps Roger devise a series of experiments he can do in the coming week to continue to evaluate whether his catastrophic or non-catastrophic explanations best explain his physical sensations. His reading assignment is Chapter 8 of
Mind Over Mood,
in which Linda does her own experiments.

In the next three sessions, Roger and his therapist continue to review and evaluate his experiments inside and outside the office. They identify a few avoidance behaviors that Roger uses for “safety” and “heart attack prevention,” such as reducing his workout at the gym. Roger conducts experiments in which he violates his safety rules to see if he can bring on a heart attack through exercise.

By the end of therapy, Roger feels 100% certain that his sensations are not catastrophic and can be explained by changes in breathing or anxiety or ingestion of caffeine. He has not experienced panic attack for two weeks. The therapist advises Roger to bring on the sensations at least once a week in the upcoming months to bolster his confidence that they are not dangerous. He can also review the treatment steps in
Mind Over Mood
if necessary.