Clinician's Guide to Mind Over Mood (16 page)

Cognitive therapy helps couples identify the beliefs and expectations that underlie anger and disappointment in their relationships (Baucom & Epstein, 1990; Dattilio & Padesky, 1990).
Love Is Never Enough
(Beck, 1988), written for couples, describes how unspoken expectations can turn hopeful love into bitter anger. The case examples in this book show readers how to evaluate and modify thoughts that maintain relationship discontent. Together,
Mind Over Mood
and
Love Is Never Enough
provide a complete therapy supplement for couples in cognitive therapy. Whereas the latter book describes the evolution of relationship conflict and recommended solutions, the treatment manual provides couples with detailed explanations and worksheets to help each person identify feelings, thoughts, and trouble spots in the relationship.

Cognitive therapy with couples has nine stages: (1) conceptualization of the couple’s problems based on history, (2) crisis management for destructive anger, (3) increasing positive interactive behaviors, (4) helping the couple learn to identify, test, and respond to problem-related automatic thoughts, (5) communications skills training, (6) exploration of issues underlying anger, (7) teaching problem resolution strategies, (8) identifying and changing maladaptive core beliefs, and (9) relapse prevention (Dattilio & Padesky, 1990, pp. 76–77). The treatment manual can help couples successfully complete each of these stages. Couples who struggle with identification of feelings can read Chapter 3. Chapter 12 provides couples with a concise overview of anger, guilt, and shame, three of the most common feelings reported during relationship difficulties. Chapters 4–7 help couples build skills for identifying and testing the silent thoughts that add to relationship distress by interfering with communication, fueling anger, and blocking positive interactions. Chapter 8 teaches strategies for solving problems and experimenting with new relationship behaviors.

A couple can learn many of the basic skills taught in the treatment manual outside the therapy hour, freeing the therapist to spend more session time helping the couple understand and change relationship difficulties. Many relationship difficulties stem from dysfunctional core beliefs (e.g., “Men can’t understand women,” “The mother is solely responsible for child care,” “True love means accepting me as I am,” “Anger is always damaging”). Chapter 9 of the treatment manual supports the work being done in therapy sessions by helping couples identify and examine the core beliefs.

It is ideal for both partners to work on core beliefs. If only one partner is doing this more intensive therapy work, the couple may conclude that this partner is more responsible for the relationship problems. All people have maladaptive core beliefs that are activated at times in their closest relationships. When awareness of maladaptive core beliefs is increased and the beliefs are replaced with balanced core beliefs, relationships thrive. If a couple does not show punitive or destructive patterns, each partner can support core belief change in the other by pointing out information to be recorded on the Core Belief Records (Worksheets 9.5 and 9.6).

As an example, Jane and Wanda sought therapy when they began to experience increased conflict in their five-year relationship. Frequent fights were fueled by Jane’s underlying assumption “If she loves me, she’ll know [and do] what I want” and Wanda’s core belief “People in love don’t criticize or fight.” A pattern of conflict developed: (1) Jane felt hurt when Wanda did not anticipate her unspoken needs. (2) Jane expressed this hurt by making small critical comments to Wanda. (3) Wanda interpreted Jane’s criticism as a sign that Jane didn’t love her anymore. (4) Wanda withdrew from Jane, feeling certain that the relationship was ending. (5) Jane became angrier, as Wanda’s attention to her decreased, until she finally exploded in anger. (6) Wanda cried in response to Jane’s anger, saying she still loved Jane and didn’t want to break up. (7) Jane was puzzled, saying she loved Wanda and only wanted Wanda to remain connected and involved. (8) Wanda felt relieved that Jane did love her and paid Jane increased positive attention during the ensuing days. (9) The relationship conflict was resolved until the next time these issues surfaced.

This couple improved when the therapist charted this pattern on a piece of paper and asked each woman to examine the core belief that contributed to her portion of the conflict. Jane recognized logically that Wanda might not always know what Jane wanted unless Jane directly communicated her wishes. However, she discovered that this core belief was activated anyway when she was emotionally tired and most prone to irritability.

On core belief worksheets, Jane noted data that contradicted her belief. For example, Jane realized that as much as she loved Wanda, she often did not have a clue to what would please Wanda in a given moment. Jane interviewed friends and discovered that they also frequently misunderstood their partner’s needs when the needs were not explicitly expressed. In therapy sessions, Wanda helped Jane understand that her love was deep but not omniscient.

In turn, Wanda examined her own core belief “People in love don’t criticize or fight.” She interviewed friends in good relationships and discovered that they all fought and criticized sometimes. She worked on developing an alternative core belief, “People who are in love use fights and criticism to improve their relationship.” To test this new perspective, Wanda tried to fight constructively in conflicts with Jane instead of withdrawing. During conflicts in session, the therapist coached Wanda to help her remain active, listening to Jane’s concerns and expressing her own. In time, Wanda and Jane each developed more adaptive core beliefs that supported interactive conflict resolution. New beliefs and skills gained in therapy and supported by the treatment manual helped them restore a mutually loving relationship.

Often people seek therapy for help with distress that follows recent life stresses or changes. Cognitive therapy is helpful for adjustment disorders. Therapists treating clients with adjustment difficulties are encouraged to structure
Mind Over Mood
use to meet clients’ immediate individual needs. Follow the guidelines for constructing individualized treatment protocols in the Helpful Hints box on
pages 108–109
. Construct a model with the client for understanding his or her problem(s) and how life events and their meanings for the client triggered problems (Persons, 1989).

Next, consider what skills are necessary to help the client navigate this challenging time in his or her life. Some clients may not know how to identify their emotions and may initially benefit most from Chapter 3 (Identifying and Rating Moods). Other people are fully aware of what they are feeling and capable of articulating their feelings. For these clients, Chapter 3 can be eliminated or skimmed.

Many clients wonder why a certain change or event has been so distressing when they have managed other problems in their life with ease. These clients can use Chapter 5 to help identify their thoughts about the event. Understanding an event’s meaning often provides useful clues regarding the importance of the event to the client and reasons for particularly strong reactions to it. Chapter 8 will help clients if an Action Plan is required to solve problems.

Refer to
Chapter 7
of this clinician’s guide for suggestions on how to use Chapters 8 and 9 in the treatment manual to work with lifelong dysfunctional core beliefs and behavior patterns if they play an important role in the presenting problem.
Chapter 7
also includes hints for resolving problems that might arise in the therapy relationship.

In lieu of a Troubleshooting Guide for this chapter, we offer a bibliography of texts and reference materials to help therapists conceptualize and construct protocols for the diverse client problems that can be helped with
Mind Over Mood.

Baucom, D., & Epstein, N. (1990).
Cognitive-behavioral marital therapy.
New York: Brunner/Mazel.

Beck, A.T. (1988).
Love is never enough.
New York: Harper & Row.

Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993).
Cognitive therapy of substance abuse.
New York: Guilford Press.

Dattilio, F.M., & Padesky, C. A. (1990).
Cognitive therapy with couples.
Sarasota, FL: Professional Resource Exchange.

Epstein, N., Schlesinger, S., & Dryden W. (1988).
Cognitive-behavioral therapy with families.
New York: Brunner/Mazel.

Freeman, A., & Dattilio, F.M. (Eds.). (1992).
Comprehensive casebook of cognitive therapy.
New York: Plenum Press.

Freeman, A., Simon, K.M., Beutler, L. E., & Arkowitz, H. (Eds.). (1989).
Comprehensive handbook of cognitive therapy.
New York: Plenum Press.

Garner, D.M., & Garfinkel, P.E. (Eds.). (1985).
Handbook of psychotherapy for anorexia nervosa and bulimia.
New York: Guilford Press.

Golden, W.L., Gersh, W.D., & Robbins, D.M. (1992).
Psychological treatment of cancer patients: A cognitive-behavioral approach.
Boston: Allyn and Bacon.

Kingdon, D.G., & Turkington, D. (1994).
Cognitive-behavioral therapy of schizophrenia.
New York: Guilford Press.

Scott, J., Williams, J.M.G., & Beck, A.T. (Eds.). (1989).
Cognitive therapy in clinical practice: An illustrative casebook.
New York: Routledge.

Many clients who seek therapy for depression, anxiety and the other presenting problems described in
Chapters 4
through 6 of this guide also meet diagnostic criteria for personality disorders (Axis II of DSM-IV). Clients with Axis II disorders and even some with long-term Axis I disorders (e.g., long-term dysthymia) can be differentiated from clients with short-term difficulties by the presence of strongly held negative core beliefs, or schemas. While all of us have schemas, including maladaptive schemas, the maladaptive schemas of clients with lifelong problems are believed to maintain their difficulties because they are not balanced by the presence of adaptive schemas (Padesky, 1994a).

Cognitive theory hypothesizes that schemas are formed in response to real developmental circumstances (e.g., growing up with manipulative, damaging others) and/or biological influences rather than from gross distortions of experience. Most of us develop both positive and negative schemas regarding our self (e.g., “I’m competent,” “I’m incompetent”), others (e.g., “People can be trusted,” “People can’t be trusted”), and the world (e.g., “The world is overwhelming,” “The world is manageable”). These schemas are differentially activated depending on mood (e.g., when depressed our self-critical, hopeless schemas emerge; when happy, our more positive self, other, and world schemas emerge), circumstance (e.g., in a dangerous neighborhood, schemas of vulnerability emerge; at home, schemas of safety emerge), recent life events (e.g., following trauma, schemas of vulnerability and mistrust emerge), and even biology (e.g., physiological activation, fatigue, and illness can influence schema activation).

According to cognitive theory, clients with Axis II disorders hold negative schemas in certain domains without a well-developed companion positive schema (Padesky, 1988, 1994a). These clients maintain certain schematic views regardless of mood, circumstance, life events, or biological state. For example, a client with dependent personality disorder sees himself as weak even following a personal mastery experience. A client with avoidant personality disorder views herself as inadequate even when she is valued as a mother by her children, loved by her husband, and regularly promoted in her job.

Although negative schemas may not be the cause of personality disorders, they serve a powerful maintenance function (Padesky, 1994a). Negative schemas emerge in the therapy relationship and can lead to noncompliance factors (e.g., “I’m a failure. What’s the use in trying anything new?”) or relationship difficulties (e.g., “I can’t trust anyone. You’ll hurt me, too.”). Negative schemas interfere with client ability to recognize progress (e.g., “Oh sure, I was promoted in my job, but that’s just because my boss doesn’t see the real me”), accept positive feedback (e.g., “You have to say that because you’re my therapist”), or learn from setbacks (e.g., “Of course it didn’t work out. I’m no good. There’s no reason to problem solve and try again”).

According to schema theory, we can perceive only what our schemas prepare us to see. Life experiences that contradict our activated schema are discounted, distorted, not noticed, or viewed as an exception to broader “reality” (Padesky, 1993b). Therefore, if we have paired schemas (“I am lovable,” “I am not lovable”), we are capable of perceiving and remembering both positive and negative reactions from other people. However, if we hold only the negative schema for certain areas of our life, we are able to perceive and remember only experiences in that domain insofar as we fit them to our schema. For example, a woman who believes “I’m unlovable” without the companion schema “I’m lovable” perceives every human interaction as proof of her unlovability. Negative responses from others fit her schema perfectly. Positive reactions from others are not noticed or distorted (“She is so kind to act nice toward me, even though I probably disgust her”), discounted (“He probably says this to everyone”), or seen as an exception (“Oh, sure, she likes me now. But when she gets to know the real me she’ll see how unlovable I am”).

Beck and his colleagues (1990) specify schemas that seem to maintain each of the personality disorders and articulate treatment plans for each disorder. As described in their book, cognitive therapy of personality disorders involves using the therapy relationship as a schema laboratory in which the client can safely evaluate maladaptive core beliefs. The developmental origins of schemas are explored so that the client can understand the circumstances under which the schemas are adaptive and learn to recognize when life circumstances allow alternative schemas to be safely held. The therapy hinges on weakening client conviction that negative schemas are always true and constructing alternative schemas so that the client can perceive and accept positive as well as negative data (Padesky, 1994a). Behavioral experiments designed to practice more adaptive behavior patterns and to test the utility of alternative schemas also are central to the therapy.

Can a treatment manual be helpful for these clients? If it can, does it need to be introduced or used any differently? How does
Mind Over Mood
fit with the cognitive therapy treatment of personality disorders described by Beck and colleagues (1990)? This chapter suggests strategies for using
Mind Over Mood
to (1) assist treatment of Axis I clinical disorders or psychosocial problems in clients with personality disorders and (2) change core schemas and problematic behavior patterns when the focus of treatment is the personality disorder itself.