Clinician's Guide to Mind Over Mood (15 page)

To decide how to use the treatment manual in therapy for problems not specified in this clinician’s guide, follow the steps in the Helpful Hints box on the following page.
Mind Over Mood
provides a framework to help clients learn skills that are essential to improved psychological functioning. In evaluating clients, it is important to assess what strengths and attributes they possess as well as what skills need improvement. The treatment manual can help clients understand their problems better, identify feelings, identify thoughts, gather data that support and contradict beliefs, generate alternative views of situations, develop Action Plans and coping strategies, identify and test assumptions and core beliefs, and develop and test new assumptions and core beliefs. Most therapy protocols aim to help clients learn some or all of these skills to solve particular problems. Therefore, therapists are encouraged to assign treatment manual chapters that teach the skills of greatest help to a client. Use relevant chapters in the clinician’s guide to troubleshoot problems that arise.

Cognitive interventions designed to reduce substance abuse are detailed in
Cognitive Therapy of Substance Abuse
(Beck, Wright, Newman, & Liese, 1993). Cognitive therapy helps clients reduce the frequency and severity of drinking or drug use by uncovering, examining, and altering the thoughts and beliefs that accompany urges to use. In addition, cognitive therapists teach coping skills to addicted clients so that drug and alcohol use are replaced with other strategies for managing moods, social situations, and life problems.

The cognitive principles outlined in
Mind Over Mood
generally can be taught in the order written when treating substance abusing or addicted clients. Clients with substance abuse problems often avoid emotions. The basic information regarding identification of moods in Chapter 3 of the treatment manual is important for them to learn early in therapy. Once clients can identify moods, they can learn to understand the causes of moods and new strategies for coping with their problems. Clients who do use alcohol and drugs to numb mood are not very motivated to change their behavior.

Early in therapy you should help your client identify beliefs about the benefits of drugs and alcohol. For example, thoughts such as “I need a drink to ease my pain,” “I’ll be more sociable if I have some coke,” or “I won’t be able to cope if I don’t use” are common thoughts that accompany the urge to drink or use drugs. These thoughts can be identified, evaluated and eventually altered using the skills taught in Chapters 4 through 7 of
Mind Over Mood.
It is often helpful to set up collaborative behavioral experiments to evaluate these beliefs (Chapter 8) rather than simply arguing against drug or alcohol use.

Chris, a 21-year-old mechanic, entered therapy at the insistence of his parents who were concerned about his depression. At intake, Chris revealed that he was using cocaine nearly daily to cope with “bum moods.” While Chris was willing to undergo treatment for depression, he did not want to discuss his cocaine habit because “it’s not harmful; it’s one of the few things that makes me feel better.” When his therapist suggested that the cocaine might actually be contributing to his depression, Chris became defensive and said that it was not a problem for him and he didn’t want to talk about it any more.

Following the guidelines for depression treatment outlined in
Chapter 4
of this guide, Chris’s therapist asked him to read the Prologue and Chapter 10 of
Mind Over Mood
to learn more about depression. Chris agreed to complete a Weekly Activity Schedule (Worksheet 10.4) to track his depressed mood. Since Chris felt cocaine was an important mood assist, his therapist suggested that he also mark his cocaine use on the Weekly Activity Schedule.

The data in the Weekly Activity Schedule Chris brought to the next appointment yielded several patterns. First, while Chris was depressed throughout the week, his mood ratings fluctuated considerably. Contrary to Chris’s belief, cocaine use was not always followed by improved mood. Even when his mood was improved while on cocaine, Chris noticed that his depression always worsened several hours after snorting cocaine.

Although one week of data did not shift Chris’s beliefs or willingness to stop using cocaine, the therapist persisted in using guided discovery to direct Chris’s attention to some of the negative aspects of cocaine use. After four weeks of therapy, Chris was willing to begin doing experiments in which he reduced his cocaine use when depressed. He began identifying and testing beliefs associated with both depression and drug use following the guidelines in
Mind Over Mood.
Within another month, he was experimenting with prolonged abstinence from cocaine and was enjoying a noticeable decrease in depression. Eventually Chris stopped using cocaine entirely and also reduced his binge drinking to two or three beers on weekends, with a commitment to himself not to drink at all when he was depressed or upset.

Like Chris, many people who have a substance abuse problem also have mood or relationship problems.
Mind Over Mood
can be used as described in this guide to help people with substance abuse problems alleviate associated difficulties. Chapters 10 through 12 provide brief overviews to help clients understand depression, anxiety, anger, guilt, and shame, moods that commonly accompany substance abuse. The medication sections in Chapters 10 and 11 address addiction risk, a common concern of clients recovering from chemical dependency.

Some addicted clients have life problems (e.g., physical disabilities) or face social disadvantages (e.g., racial discrimination or high community unemployment rates) that seem hopeless to them. The problem-solving strategies described in Chapter 8 can help people begin to create Action Plans to cope with even the most difficult life circumstances. Extremely depressed clients with high levels of hopelessness need to be helped by their therapists to develop and carry out Action Plans.

As an example, an inner-city crack addict, Jim, had fewer internal and external resources than Chris, the employed mechanic who abused cocaine. A creative therapist was a powerful resource for Jim, helping him to come up with a small-steps plan for improvement. The first step was a medical detoxification program. The second was finding safe and drug-free housing. Over time, the therapist helped Jim enter a support group and find and maintain a job. The plans for changing Jim’s life triggered both adaptive and maladaptive emotions and beliefs. The emotions and beliefs that interfered with progress were identified and tested using the strategies taught in Chapters 3 through 7 of
Mind Over Mood.

Sometimes drug and alcohol abuse are associated with chronic low self-esteem or dysfunctional beliefs that maintain problems. Once clients have learned the skills taught in the first eight chapters of
Mind Over Mood,
these deeper core issues can be addressed following the strategies described in Chapter 9 of the treatment manual.
Chapter 7
in this therapist’s guide describes how to use Chapter 9 of the client manual to change core beliefs.

Relapse prevention is an important part of any substance abuse treatment program. The Action Plans described in Chapter 8 can be used to anticipate and plan for situations in which a client is at high risk to use alcohol or drugs. Many clients struggling with substance abuse or addiction identify with Vic, a recovering alcoholic described in
Mind Over Mood.
Chapters 6 and 7 of
Mind Over Mood
describe in detail how Vic used the manual’s worksheets to prevent relapse drinking during a period of intense anger with his wife, Judy. In Chapter 8, clients can read how Vic set up an Action Plan to cope with his anger and improve his relationship with Judy while maintaining sobriety.

Mind Over Mood
is compatible with 12-step programs including Alcoholics Anonymous (AA), Narcotics Anonymous, and Al-Anon as well as with inpatient and outpatient programs (e.g., Rational Recovery, S.M.A.R.T. Recovery) treating alcohol and drug dependency. Group treatment programs can use
Mind Over Mood
as a treatment guide for clients following the principles for group therapy outlined in
Chapter 9
of the clinician’s guide.

Twelve-step programs can select particular chapters from the treatment manual to help members successfully complete steps and avoid common pitfalls. For example, the fourth step in an AA program asks members to “make a searching and fearless moral inventory” and the fifth step directs members to admit wrongs to “God, to ourselves, and to another human being” (Alcoholics Anonymous, 1976, p. 59). Some AA members have an exaggerated response to these steps and blame themselves totally for every misfortune in life. Extreme self-blame can lead to overwhelming feelings of hopelessness and self-reproach, which in turn can increase a member’s risk for renewed substance abuse.

Chapter 12 of the treatment manual helps 12-step program members understand and work with guilt and shame. Responsibility Pies (Worksheet 12.2) help AA members acknowledge responsibility without assigning excessive self-blame. This method is particularly helpful for women, who are prone to accepting excessive blame and responsibility for problems, ignoring other contributing factors.

Fairburn (1985) and Garner and Bemis (1985) provide some of the clearest descriptions of cognitive therapy for eating disorders. Interested therapists can also read about this approach in the
Handbook of Psychotherapy for Anorexia Nervosa and Bulimia
(Garner & Garfinkel, 1985). All the skills taught in
Mind Over Mood
are useful for eating disorder clients. Clients with eating disorders should read the Prologue and then the portions of Chapters 10 through 12 that pertain to them. The remaining chapters can be read in the order written.

The one exception to this general guideline is that the Weekly Activity Schedule (Worksheet 10.4) is almost always helpful at the beginning of therapy for eating disorders. The Weekly Activity Schedule assesses the relationship between activity/behavior and mood. This worksheet can be modified for eating disorder clients to identify precipitants of increased levels of emotional distress, binging, purging, overeating, exercise, or other problems. Instruct clients to rate moods following the directions for this worksheet, and also to highlight with a star or other marker times when binging, purging, or other target behaviors occurred. Use Worksheet 10.5 to examine the connections among general behaviors and activities, eating disorder behaviors, and mood.

This assessment exercise is often followed by interventions that restructure activities to improve coping with precipitants of eating disorder behaviors. For example, one client with bulimia discovered that she binged and purged following weekly phone calls with her critical parents. She reduced her phone calls home and asked a trusted friend to sit with her during bi-monthly calls to offer her support and help counter negative thoughts that followed harsh parental criticism. As this client discovered, Action Plans (Chapter 8) that specify alternative coping strategies to binging, purging, and starvation are very helpful for eating disorder clients.

Like clients with substance abuse problems, clients with eating disorders often have difficulty identifying, differentiating, and rating emotions. Chapter 3 of the treatment manual can help clients attain these skills. Central to cognitive therapy of eating disorders, however, is restructuring of thought patterns that maintain the disorder. Chapters 4 through 7 teach clients to identify and test automatic thoughts, and Chapter 9 can be used to modify the deeper assumptions and core beliefs that are usually the center of the eating disorder storm.

Overeating and bulimia are usually easier to treat than anorexia nervosa. Clients with the first two disorders can usually perceive clear links between moods and impulsive eating behaviors. Once these clients learn to identify moods and delay eating behaviors to cope with these moods more directly, eating disorders diminish. For example, one client with bulimia learned to use her impulses to binge or purge as cues to look for the presence of an emotion. After learning to complete Thought Records, she used them to understand and work with her emotions prior to binging or purging. Most of the time, she felt better after completing a Thought Record. A reduction in emotional intensity made it easier for her to replace binging and purging with relaxation, assertion, or work on an Action Plan to solve an identified problem.

Clients with anorexa nervosa can also be treated with cognitive therapy, but they often demonstrate less emotional and cognitive awareness than bulimic clients, especially if the anorexia has progressed to the point of severe weight loss. Cognitive and emotional impairment are evident at very low body weight. Therapists focus on development of a positive and collaborative therapeutic relationship with low-weight anorexic clients rather than on teaching higher-level cognitive or emotional skills. If anorexic clients are strong enough to read and concentrate, they benefit from reading Chapters 1 through 3 and Chapters 10 through 12 of
Mind Over Mood
and completing the worksheets in these chapters.

Cognitive flexibility usually increases along with weight in clients with severe anorexia nervosa. Chapters 4 through 9 of the treatment manual are helpful to these clients when they gain enough weight to participate actively in psychotherapy. Common beliefs in anorexic clients include an assumption that self-worth is measured by body weight or shape, the conviction that complete self-control is desirable, and perfectionistic standards (Garner & Bemis, 1982, 1985). Therapists working with these sorts of beliefs are cautioned not to dispute them logically. Patient guided discovery with eating disorder clients is much more helpful than direct challenge of beliefs.

As an example, Cathy and her therapist identified two beliefs that were central to her anorexia nervosa: “I am as perfect as my weight” and “If I am not perfect, I am worthless.” Since Cathy’s idea of the perfect weight was so low it was medically dangerous, she needed to be hospitalized to regain weight she had lost. Then Cathy and her therapist used scales in Chapter 9 of the treatment manual and behavioral experiments in Chapter 8 to gradually shift Cathy’s beliefs over an eight-month time period.

Cathy rated herself and others on her standards of perfection and discovered that she applied different weight rules to herself and to others. She also used rating scales to evaluate “perfection” and “worth” in a variety of areas of her life not directly tied to body weight. For example, she rated violin practice sessions on scales of perfection and worth. Cathy discovered that some practice sessions in which her playing was quite imperfect still had worth if she was able to learn something that improved her overall playing. Over time, Cathy began to see flaws in her underlying beliefs about perfection and worth. As she loosened perfectionism in other areas of her life, her concerns for maintaining a perfect weight also decreased.

Treatment of eating disorders can be straightforward or quite challenging. Treatment approaches require thorough knowledge of medical and psychosocial aspects of the disorder (for example, family patterns sometimes help maintain the problems) as well as the cognitive and behavioral components helped directly by the treatment manual.