Clinician's Guide to Mind Over Mood (2 page)

A new client, Joan, arrives for an intake appointment. In this first meeting, you learn that Joan is depressed, has a five-year history of cocaine abuse, recently became unemployed, and has concerns about her teenage son’s truancy from school. Joan is still covered by the insurance plan from her previous job. Her mental health benefits allow eight outpatient therapy sessions and do not allow family therapy. Joan seems motivated to make a change in her life, and you think you could help her more if you weren’t limited to eight sessions.

Peter, age 36, began therapy six months ago when his father died. With a 20-year history of generalized anxiety disorder, Peter was skeptical that therapy could help. However, he now sees you as someone who can help him find his way in life. Peter has adopted a dependent style in therapy. He presents you with a new problem each week and asks you for guidance. When you ask Peter what he has learned in previous discussions that might help solve his current problems, he replies, “I don’t know. When I get anxious I can’t remember what we’ve said.”

How often do you face these types of scenarios? Many clients, like Joan, need more therapy than we can provide. Others, like Peter, need to independently apply what is discussed in therapy. Joan, Peter, and their therapists would benefit from the use of a client treatment manual such as
Mind Over Mood: Change How You Feel by Changing the Way You Think.

A client treatment manual provides a structure for therapeutic intervention beyond the therapy hour. Joan’s therapist could use therapy sessions to construct plans to solve the crises and problems in Joan’s life and help Joan enroll in a drug treatment program. The therapist could assign chapters in
Mind Over Mood
to be read between therapy appointments to help Joan learn skills to lessen her depression and cope with the thoughts and feelings maintaining her cocaine use. The client manual might provide enough support so that Joan’s last two or three appointments could be spaced several weeks apart without jeopardizing Joan’s progress. Joan could also use the client manual after therapy has ended to guide continued improvement.

A client treatment manual also helps summarize and organize learning so that clients can remember and use what has been discussed in therapy. Peter’s therapist could recommend
Mind Over Mood
as a tool for fostering independent problem solving. The exercises in the manual would help Peter learn skills to help manage his own anxiety. For Peter, the client manual would provide a bridge between reliance on his therapist and dependence on himself. Undoubtedly, Peter’s feelings and thoughts about becoming independent would emerge as he began to use the manual. The feelings and thoughts could be discussed in therapy sessions and also explored by Peter on the worksheets in
Mind Over Mood.

Many therapists have never used a client treatment manual as part of therapy.
Figure 1.1
provides a decision tree to help you decide if the manual might be helpful. This chapter provides specific suggestions to help you integrate
Mind Over Mood
into therapy. Subsequent chapters in this book specify treatment protocols for using
Mind Over Mood
with a range of client problems to provide focused treatment for a variety of client problems in a variety of treatment settings. Since
Mind Over Mood
is a cognitive therapy (CT) treatment manual, we begin with a discussion of the critical components of cognitive therapy and how to use a client treatment manual in CT.

FIGURE 1.1
. Decision tree for use of
Mind Over Mood.

A complete description of cognitive therapy includes cognitive theory (e.g., Beck et al., 1990; Beck, Rush, Shaw, & Emery, 1979), cognitive models for case conceptualization (see Beck et al., 1990; Persons, 1989), and specific treatment protocols for different client problems. Cognitive therapy texts that provide full descriptions of the therapy are cited throughout this book and can be consulted for elaboration of the theory and treatment approaches.

Cognitive therapists assess thoughts, moods, behaviors, biology, and environment in understanding the origin of client problems. These five areas of life are interconnected, each part influencing the others. Although cognitive therapists may intervene in any or all of the five areas to help a client, cognitive therapy places particular emphasis on identifying and evaluating thoughts and on behavioral change.

The focus on thoughts does not mean that cognitive therapists believe that thoughts cause all problems. However, thoughts play a powerful role in maintaining dysfunctional moods and behaviors regardless of their origins. For example, a woman may become depressed following a great personal loss in combination with a genetic predisposition toward depression. Even if her depression is conceptualized as resulting from environmental and biological stressors, a cognitive focus would be an important part of the treatment. Once depressed, her thoughts become characteristically negative, as described by Beck (1967).

Each emotional state, regardless of origin, is accompanied by characteristic patterns of thinking. Anxiety is accompanied by thoughts of danger and vulnerability; anger by thoughts of violation and unfairness. Therapeutic change is hampered if these thoughts are not identified and evaluated. For example, the course of treatment for the depressed woman might include establishing supportive relationships in her time of loss. She might refuse to make these contacts because of characteristic thinking patterns that occur in depression: “It won’t help” (hopelessness), “I’m no fun to be around” (self-criticism), and “I don’t enjoy myself anyway” (global negativity).

Cognitive therapists teach clients to identify, evaluate, and change dysfunctional thinking patterns so that therapeutic changes in mood and behavior can occur. These changes often help clients change their environment (e.g., “If I have worth, maybe I deserve more nurturing relationships”) and may be accompanied by biological shifts. Three levels of thoughts are addressed in cognitive therapy: automatic thoughts, underlying assumptions, and schemas (the less technical term “core beliefs” is used in
Mind Over Mood
)
.

Automatic thoughts are the moment-to-moment, unplanned thoughts (words, images, and memories) that flow through our minds throughout the day. Underlying assumptions are cross-situational beliefs or rules that guide our lives; they include “should” statements (“A woman should always think of her children first”) and conditional “if . . . then” beliefs (“If people get to know me, they will reject me”). Underlying assumptions guide behavior and expectations, although often they are not articulated consciously.

Schemas have been described as screens or filters that process and code stimuli (Beck et al., 1979). In this clinician’s guide, the word
schema
is used to describe absolutistic core beliefs about the self, others and the world. Schemas are absolute (“I am strong”) and dichotomous (“I am strong,” “ I am weak”). As discussed in
Chapter 7
of this guide, schemas are central in the treatment of clients with personality disorders and other lifelong problems.

The three levels of thought are interconnected. Schemas (“I’m unlovable”) give birth to underlying assumptions (“If people meet me, they won’t like me”); together they determine what types of automatic thoughts occur (“I won’t have any fun at the party” is more likely to accompany an unlovability schema than “I’ll go to the party and make some friends”). Many cognitive therapy texts label only two levels of thought, automatic thoughts and schemas. We believe three levels are helpful because therapists can differentially choose therapy methods based on the type of thought to be evaluated. Automatic thoughts are best evaluated on Thought Records (
Mind Over Mood,
Chapters 4–7), underlying assumptions are usually tested with behavioral experiments (
Mind Over Mood,
Chapter 8) and change in schemas is effected by learning to rate experiences on a continuum and to use a variety of core belief logs (
Mind Over Mood,
Chapter 9).

Understanding the interplay between levels of thought and moods, behavior, physical functions, and environment is central to cognitive theory and practice. Two fundamental clinical processes underlie the therapy itself: a collaborative therapy relationship and guided discovery. Since these two factors are critical to the successful use of
Mind Over Mood,
suggestions for implementing them are described here.

A positive therapist–client relationship is a critically important foundation for successful therapy. Clients are most likely to honestly and openly discuss problems in a relationship that seems safe and trustworthy. The best cognitive therapists are warm, empathic, and genuine with their clients, qualities basic to any good therapeutic relationship. These qualities are demonstrated in the therapist’s straightforward curiosity about the client’s experiences, thoughts, and feelings and by the efforts the therapist makes to devise a brief and effective therapy plan to help the client improve quickly. To fit with this type of therapy relationship, a treatment manual should be introduced to the client as a caring assist to client progress, not as a therapist convenience.

Cognitive therapy adds “collaborative” to the list of qualities important to the therapy relationship. Collaboration requires an active stance on the part of both therapist and client to work together as a team. Since many clients enter therapy expecting to play a more passive role (“Fix me”), the therapist often needs to socialize the client to expectations for mutual collaboration.

A collaborative therapist conveys to clients that they have important information that must be shared to solve problems. The therapist knows general strategies and treatment models, and the client holds all the information about his or her unique experiences and is the only one who can describe thoughts and moods. The client’s experience dictates how general principles will be applied to help current problems. Collaboration also allows the client to give feedback to the therapist and ask questions to learn as much as possible to make informed choices and decisions. In cognitive therapy, the therapist agrees to respect and encourage collaborative exchanges.

A warm therapy relationship without visible progress in solving presenting problems can actually make a client feel worse over time.
Mind Over Mood
helps establish a collaborative therapy relationship that promotes client progress in three ways. First, the manual encourages client independence from the therapist in learning therapeutic approaches to solving problems. The more a client learns to solve problems independently, the greater the chances he or she will take the steps necessary for life improvement. Second, the worksheets in the manual actively enlist the client’s efforts to apply what is learned in therapy to everyday life experiences. The worksheets highlight the client’s observations and insight. Worksheets are reviewed in therapy as a visible record of learning and participation. Third, the worksheets provide immediate feedback to client and therapist about whether the client understands the skills taught in therapy and whether the skills are helpful in correcting target problems.

If actual or perceived violations in trust, confidence, interpersonal comfort, or respect disrupt the therapy relationship, client progress may suffer. Therefore, the therapist should regularly ask the client for feedback about the therapy relationship and procedures. If clients are asked for feedback about therapy progress and the therapy relationship in each session, they become more comfortable raising concerns as they arise. Any disruptions in collaboration should be discussed and mutually resolved as soon as possible.

As an example, Roy said that he thought his therapist was trying to hurry him out the door at the end of each session. Notice how the therapist respectfully collaborated with Roy to solve the problem.

T:   We have only five minutes left today, so let me get some feedback from you on how the therapy is going for you and any reactions you might have to our relationship.

R:   Well, it’s going pretty OK.

T:   You say that with some hesitation. Is there something that could be better for you?

R:   Yes. It’s this endpoint every week. I don’t like the idea that you watch the clock. It’s like you want to hurry me out of here.

T:   What exactly do I do that gives you that impression?

R:   Well, you always tell me when there are a few minutes left. And I always leave between ten and five minutes before the hour is up. I thought therapy was a whole hour long.

T:   And so you figure that means I am hurrying you out faster than usual.

R:   Yes.

T:   And how does that feel to you?

R:   I feel like I’m unimportant to you.

T:   Does that make you feel sad? or angry? or something else?

R:   A little angry I want to have my full amount of time.

T:   I’m very glad you’re bringing this up today. Do you have more to say about what this means to you, or would you like to hear what it means to me?

R:   I would like to know how you feel.

T:   First, I’m not aware of feelings that I want to hurry you out of here. However, its always possible I am feeling pressured to hurry sometimes. Although I don’t think that has to do with you personally, I will pay attention to my feelings to see if those feelings are there. If so, I’ll try to figure out with you what prompts them and how we can work together to keep a good relationship.

R:   But you seem so aware of the time.

T:   Does it seem that way to you the entire session or just at the end?

R:   Not in the beginning or middle. Just at the end when you get me to leave early.

T:   This is where I have done a poor job of communicating to you, Roy. You see, I try to end all my appointments ten minutes before the hour. I use the time after you leave and before my next appointment to make notes on what we talked about and to write myself reminders of what topics I think it is important for us to discuss in the next session. Before we meet, I read those notes and try to get myself ready to continue our work together. So, while we only meet for
50
minutes, I spend about an hour on each session.

R:   I wondered how you remembered so much about me.

T:   Just as I ask you to write things down between sessions, I need to do that too. I should have explained this to you clearly at the first session so you knew to expect only a 50-minute meeting. I’m sorry.

R:   Well, I feel better knowing you do this with everyone.

T:   I wonder if the way I tell you there is only five minutes left also makes it harder for you in some way.

R:   Yes. I know why you do it. But it surprises me sometimes because some weeks the time goes so quickly.

T:   What would it be like for you if I didn’t say, “Five minutes left”?

R:   (
Pause
) It would be worse for me if the end of the session came and I wasn’t expecting it.

T:   I do let you know so we can cover whatever else is important to you to discuss. But maybe there’s a better way for me to signal you.

R:   I have a setting on my watch to make it beep at a certain time every hour. Maybe I could set it to go off at 5:45, and then we’d know.

T:   That’s a great idea. Would you be willing to do that?

R:   Yes. And then I’d feel a little more in control of our time.

T:   Let’s try that next week. Let’s also both think more about this discussion to see if there is more to say. I’m going to make a note that you feel better when you are in control of the time. We may want to look more at this issue of feeling in control because it might relate to some of your relationship problems we’ve been discussing.

R:   OK.

T:   Before you leave, how are you feeling right now about our relationship and what we’ve just discussed?

R:   Better. I was nervous bringing this up, but I’m glad I did.

T:   I am, too. Please bring up any other concerns you have so we can have a chance to work them out together.

R:   OK. I will.

In this therapy excerpt the therapist truly collaborates with Roy in exploring his concerns. She asks him to describe his thoughts and feelings about session endings and also discusses her own thoughts and feelings. Rather than seeing the issue as all internal to Roy, she takes responsibility for her inadequate communication to him about session time. Once the situation is mutually understood, Roy and the therapist discuss mutually agreeable solutions. If Roy did not suggest his wristwatch, the therapist might suggest placing a clock in the therapy room so that they could both keep track of the time. Or they might agree that she will continue to note when the session is almost over. Collaboration implies mutual problem solving rather than one-sided decision-making. For example, the therapist would not accept a request from Roy that sessions last until he feels ready to end.

Although almost all clients who used earlier versions of
Mind Over Mood
responded positively, use of a client treatment manual may occasionally create friction in the therapy relationship. Therapists who follow the guidelines for using the client manual described in this clinician’s guide will rarely encounter difficulties in its use. However, a few clients may have negative reactions to the idea of using a manual.
Chapter 7
of this guide describes several negative client reactions to a client manual and explicit therapeutic strategies for responding to them.