Clinician's Guide to Mind Over Mood (14 page)

The following excerpt illustrates how didactic information can be conveyed via guided discovery. Guided discovery reduces the likelihood that the client will respond “Yes, but . . .” to information related to the reduction of medication.

T:   You have been unwilling to experiment with going into a meeting without taking a small dose of Xanax. I’d like to discuss that decision today.

C:   I know you don’t want me to take the medication. But I don’t think it hurts anything and it helps me not avoid the meetings, like I used to.

T:   That’s the advantage of the medication. Can you think of any disadvantages?

C:   No.

T:   What do you think would happen if you didn’t take the medication?

C:   I’d probably get panicky and leave the meeting.

T:   What would be an alternative to leaving if you became panicky?

C:   Well, I suppose I could try practicing relaxation, and I could also identify and test my thoughts.

T:   How confident are you that these strategies would work as well as the medication?

C:   If I’m honest with you, not very confident.

T:   That’s what I thought. What would it take for you to become confident?

C:   I guess I’d have to try them out without medication and see if they work. But it’s just too risky to try that at a meeting where I could make a fool of myself in front of customers.

T:   Suppose you had a friend whom you wanted to encourage to get off medication. What would you advise him in this situation?

C:   (
Smiling
) You’re tricking me.

T:   I don’t mean to trick you. It just seems that you can think of only one way to handle this for yourself. I thought maybe you could get more ideas if we shifted the focus off you.

C:   Well, I might tell my friend to try not taking the medication before a meeting that is less pressured. In some meetings I don’t have to say much. Or I could take the medication with me and only take it if my anxiety gets bad and the other techniques don’t work.

T:   Those are two good ideas you could try out. How long would it take the medication to work if you did take it as a last-minute backup?

C:   Usually I feel better within a few minutes.

T:   Really?

C:   You seem surprised.

T:   I am. Xanax usually takes at least 15 or 20 minutes to take effect. Do you really feel better within a few minutes of taking it?

C:   Yes, I do.

T:   Then how would you explain that? Why do you think you feel calmer in a few minutes if the medication takes 15 to 20 minutes to have a physiological effect?

C:   Maybe because I feel reassured that help is on the way.

T:   So your confidence in the Xanax might help you even before the medication does?

C:   Yes, that makes sense.

T:   Does it also make sense then that increasing your confidence in relaxation and the cognitive methods you’ve been learning in
Mind Over Mood
might help make these methods more helpful, too?

C:   Yes, I think it would.

T:   Perhaps it’s time to do some experiments to find out if you can be as confident in these other methods as you are in the medication. Which experiment would you be willing to try first?

C:   Maybe to not take the medication at a less pressured meeting, but to still carry the medication with me in case my anxiety gets too bad.

T:   That seems like a good place to start. Let’s review what you’ll do instead of taking medication. Also, we should make some backup plans so you don’t take the medication at the slightest hint of anxiety.

C:   (
Laughs
) Yes, I might want to do that!

It often takes a number of weeks to convince a client who firmly believes in medication that other methods can be as effective. Therefore, it is a good idea to identify beliefs about medication early in therapy so you can devise experiments to test them as soon as the client learns other anxiety management strategies. Clients who have been on medication long enough to experience withdrawal effects when the medication is reduced should be warned of the probability of temporarily increased anxiety. Withdrawal anxiety can be reframed as an opportunity to try out cognitive and relaxation strategies for reducing anxiety when the cause of the anxiety (in this case, physiological withdrawal) cannot be changed.

Many anxious clients enter therapy with a mix of anxiety problems. One client may experience panic as well as social anxiety. Another may have a long history of generalized anxiety yet enter therapy for help with a phobia. How do you know what treatment protocol to follow? One strategy is to define the different problems and ask the client which one he or she would like to tackle first. Very often, however, all anxiety problems are equally important to the client. In this case, it is helpful to see if there is a central theme that links the anxiety problems and/or the treatment protocols. Identification of overlapping themes or treatment skills needed often leads to an individualized treatment plan that meets all the client’s anxiety needs, as illustrated in the following case example.

Monique entered therapy with generalized anxiety compounded by a social phobia and recent onset of panic attacks. In the first session, Monique described herself as a perfectionist. Her father had been very punitive when she was a child, and she had struggled to do things perfectly to avoid his criticism and punishment. Throughout her life Monique experienced intense anxiety whenever she was in a large social situation and could not be sure that everyone in the room approved of her.

Monique’s anxiety intensified after she moved to a new city. She was afraid that her new neighbors and other people would notice her anxiety and think she was crazy. These thoughts were followed by increased anxiety and depersonalization experiences that Monique interpreted as evidence that she was in fact going crazy. Each time she thought she was going crazy she experienced a panic attack. Monique described herself as “caught in a storm” of anxiety.

Although Monique was experiencing three problems—generalized anxiety, panic, and social phobia—all three stemmed from her fear of criticism. The therapist therefore decided to help Monique learn to cope with criticism better so that it didn’t frighten her so much. The first week the therapist suggested that Monique read the Prologue and Chapter 11 of
Mind Over Mood.
In addition, he asked her to complete a Weekly Activity Schedule (Worksheet 10.4) to discover the pattern in her anxiety for herself.

After observing that many social situations greatly increased her anxiety, Monique learned to identify her thoughts in these situations using the guidelines in Chapter 5 of the treatment manual. These thoughts focused on the fear and certainty that others were critical of her and would punish her in some way. Using the strategies in Chapter 8, Monique and her therapist developed assertion Action Plans that she could put into effect if other people criticized her. For example, she role-played defending her anxiety to a stranger who acted in accordance with her worst-case scenario.

In role-play exercises such as this, Monique learned to speak up for herself, defending her anxiety or any other aspect of her behavior that others might criticize. She was surprised that, after repeated role-plays, she became angry with criticism and could see that it was generally unwarranted in the situations in which she feared it. By developing Action Plans to cope with the possibility of criticism, her anxiety decreased in social situations. She also became less fearful of strangers and experienced depersonalization less often. Defending her anxiety led Monique to become confident that she was not going crazy, and her panic also subsided. By pinpointing the central theme connecting all her anxiety problems, Monique and her therapist were able to help her overcome most of her anxiety in a few months using the skills taught in
Mind Over Mood.

The following table shows the types of cognitions associated with the most common anxiety problems. A brief summary of the primary treatment interventions used to help these problems is also provided along with a list of the treatment manual chapters that teach relevant skills.

© 1994 Center for Cognitive Therapy, Newport Beach, CA.

Barlow, D.H. (1988).
Anxiety and its disorders: The nature and treatment of anxiety and panic.
New York: Guilford Press.

Beck, A.T., Emery, G., & Greenberg, R.L. (1985).
Anxiety disorders and phobias: A cognitive perspective.
New York: Basic Books.

Hawton, K., Salkovskis, P.M., Kirk, J., & Clark, D.M. (Eds.). (1989).
Cognitive behaviour therapy for psychiatric problems: A practical guide.
New York: Oxford University Press.

Kennerley, H. (1995).
Managing anxiety: A training manual
(
2nd ed.
)
.
New York: Oxford University Press.

Meichenbaum, D. (1994).
A clinical handbook/practical therapist manual for assessing and treating adults with post-traumatic stress disorder
(
PTSD
)
.
Waterloo, Ontario: Institute Press.

Resick, PA., & Schnicke, M.K. (1993).
Cognitive processing therapy for rape victims: A treatment manual.
Newbury Park, CA: Sage Publications.

Steketee, G.S. (1993).
Treatment of obsessive compulsive disorder.
New York: Guilford Press.

Treatments for depression and anxiety disorders, detailed in
Chapters 4
and
5
of this guide, are the most familiar applications of cognitive therapy. There are also cognitive models and treatment protocols for almost every type of client problem, as the recommended reading list at the end of this chapter shows. This chapter outlines general principles therapists can follow in adapting
Mind Over Mood
to accompany cognitive treatment of diverse client problems. We then illustrate the application of the principles in the treatment of substance abuse, eating disorders, relationship problems, and adjustment disorders.