Clinician's Guide to Mind Over Mood (21 page)

T:   Let’s write the thought we’re testing at the top of the page.

G:   (
Gary writes, “I’m safe even if I tell Sally what I feel.”
)

T:   In the columns you can write your experiment—that’s what you’re going to do—your prediction of what will happen, and possible problems that might come up. Let’s do that for Saturday, just as an example.

G:   So, for “Experiment” I could write, “Tell Sally to back off.”

T:   That’s right. We can role-play later some different ways you could say that to her. And what was your prediction of what would happen if you did this experiment?

G:   She’d get mad.

T:   Anything else?

G:   We’d have a big fight.

T:   Anything else?

G:   She’d want to split up.

T:   Anything else?

G:   No, that’s enough!

T:   OK, write those three predictions down: Sally will get mad, we’ll have a big fight, she’ll want to split up.

G:   (
Writing
) This is where I get stuck. I don’t know what to write where it says “Strategies to overcome these problems.”

T:   Let’s talk about some strategies. I bet you’ll have a tough time doing these experiments until you have a plan for how to handle problems that could come up as a result.

G:   When she gets mad, I just freeze or else I explode.

T:   Do you know anyone who handles it well when someone gets mad at them?

G:   Actually, Sally does pretty good. She makes sales calls and customers get mad at her all the time.

T:   What does Sally do to handle it when people get mad at her?

G:   She listens and says, “I didn’t mean to make you mad” and says “I understand” and says things like “This doesn’t seem to be a good time to talk.” I don’t hear what they are saying because she’s on the phone, but that’s what I hear her saying.

T:   Do you think any of those comments would be helpful for you to use if Sally gets mad at you?

G:   Maybe. I could say, “Maybe we should talk later.”

T:   Let’s write that down. That might be a useful strategy if your fighting seems to be getting out of hand, but I’m not sure that’s the best place to start because it sounds a little like avoiding talking to her about your feelings.

G:   That’s why it seems so good! (
Laughs.
) Maybe I could say I don’t want her to be mad.

T:   OK. And what do you want from her?

G:   I want her to listen and understand why I’m upset.

T:   Do you think that would be a good thing to say to her? (
As Gary nods.
) Why don’t you write that down, too?

Gary and his therapist continued developing strategies for responding to Sally’s anger, then worked on strategies for defusing a big fight and on strategies for preventing a breakup. Gary developed several strategies to overcome each potential problem. After completing the first four columns of worksheet 8.1, Gary and the therapist role-played various problem situations and responses. At first, Gary hesitated to respond to Sally (as role-played by the therapist). The therapist coached Gary through a number of role-plays until Gary felt pretty confident that he could be assertive in the face of Sally’s anger.

As the example illustrates, common reasons clients do not follow through on behavior change assignments include intense emotions, hopelessness beliefs, negative predictions, and inadequate knowledge or skills to respond to problems that might interfere with behavior change. To successfully change maladaptive behavior patterns, therapists help clients (1) identify roadblocks to change, (2) devise strategies for overcoming them, and (3) practice new strategies in the office until the client gains confidence and skill. Chapter 8 of the manual includes worksheets to structure experiments and Action Plans, important behavioral complements to cognitive strategies for cbib-1 schemas. Alternative schemas do not have credibility to clients until real-life experiences support them.

The therapy of some clients is characterized by frequent crises that interrupt skill building and interfere with goal attainment. For these clients, a treatment manual can be a crucial aid in keeping therapy focused. It is helpful if the therapist identifies common skill deficits that may predispose a client to crisis-level problems. For example, some clients become overwhelmed by emotion and act impulsively. Other clients lack assertion and become immersed in demanding relationships and overwhelming demands. Some clients function well during the daytime when activities and structure are plentiful and sink into depths of distress at night when few supports are available. A case example illustrates the use of
Mind Over Mood
with these clients.

Patty came to therapy reporting frequent bouts of depression and anxiety. Each week she arrived with new crises: relationship conflicts, walking off her job in tears, and financial problems resulting from impulse shopping. In addition to depression and anxiety diagnoses, her therapist diagnosed borderline personality disorder. Discussion with Patty revealed that each crisis was precipitated by intense affect followed by some impulsive action on her part intended to relieve the affect.

Patty’s therapist focused initially on helping Patty identify and rate her moods (
Mind Over Mood
, Chapter 3). For each crisis, this was the first therapy task, followed by problem solving in session to resolve the crisis. Patty completed an assignment to identify and rate her moods three times per day during the initial weeks of therapy until she felt confident that she had this skill. Next, she and her therapist identified her “hot zone”: at feeling ratings above 6 she was likely to act impulsively.

Next Patty and her therapist developed specific coping plans for medium and high (ratings above 6) levels of emotion. At medium levels of affect, she was encouraged to employ active coping to reduce the risk of entering her hot zone. Active coping involved (1) making an Action Plan (
Mind Over Mood
, Chapter 8), (2) as she learned the skills, identifying thoughts and completing Thought Records (Chapters 4–7) or (3) calling one of the people on a list of five supportive people she could count on in a crisis. She was encouraged to rotate the friends she called so that none of them would feel overburdened.

Even with this plan in place, Patty often ended up in her hot zone because she frequently reached an emotional 9 or 10 rating within moments of a distressing event, so she and her therapist worked on a plan for high-affect crisis coping. The plan entailed a timeout to calm herself and make choices before acting. In-session role-plays and problem solving helped Patty learn socially acceptable ways to temporarily leave a situation (e.g., excusing herself to think it over or attend to a prior commitment with a promise to resolve the issue at some specified future time).

During her timeout period, Patty used a variety of coping methods, depending on the emotions she experienced. Usually she felt terrified or enraged, so she practiced a variety of methods to calm down when feeling these emotions. She and her therapist made a “coping grid” (Padesky, 1994b) for each emotion, a 2-by-2 chart labeled “Day” and “Night” across the top and “Alone” and “With Others” down the side. In each cell of this grid she marked coping behaviors for the target emotion.
Figure 7.2
shows Patty’s coping grid for the emotion “Enraged.”

Patty used the strategies in her coping grid until she could rate her emotions less than 6. Sometimes a few minutes of coping were sufficient, although several hours of coping practice were often required to reduce the intensity of her emotions. Once she attained a more moderate level of emotion, she was able to use
Mind Over Mood
to understand the situation better and respond to it using Thought Records (Chapters 4–7) and Action Plans (Chapter 8) if appropriate.

Identification of Patty’s skill deficits for tolerating intense moods led to initial therapy goals of learning to identify moods and manage them with behavioral coping strategies. Clients who experience intense, overwhelming affect find behavioral strategies easier to learn and practice than cognitive ones early in therapy. Once Patty learned to replace impulsive behavior with other strategies, she was more capable of using the therapy manual to understand her emotional reactions and develop problem-solving skills. The therapy manual provided structure to her learning at each step of therapy.

FIGURE 7.2
.
Patty’s coping grid.

Occasionally clients with personality disorders object to structured learning, written exercises, or some other aspect of using the treatment manual. Avoidance, suspicion, or anger could underlie client objections; case examples illustrating these reactions and therapeutic guidelines for responding to them were presented early in this chapter of the clinician’s guide. In this section, we suggest troubleshooting guidelines to help clients who object to therapy structure but do not fit into the categories described earlier in the chapter.

A negative client response to therapy should be heard and carefully evaluated. Identify client affective and cognitive reactions and find out as much as possible about what aspects of the therapy and your therapeutic style trigger them. It is important not to assume that the problem resides in the client. Clients with personality disorders can be expected to respond more strongly to interpersonal aspects of therapy than other clients; strong responses do not mean that these reactions are unwarranted.

As an example, one client felt hurt when his therapist enthusiastically pointed out a worksheet that could help him identify thoughts related to feelings of rejection. The client angrily confronted the therapist, saying she was more eager to teach him how to use the worksheet than to listen to his feelings in a situation that had been very painful for him. Fortunately, the therapist was open to client feedback. She recognized that the client was accurate in his perception. In her enthusiasm to introduce Thought Records, she had neglected to empathically listen to her client. It would have been better for her to introduce the Thought Record after she listened to and summarized his concerns.

Clients who object to written exercises and other aspects of therapy structure often do so because they fear that structure will reduce the quality of the therapy relationship. If this concern is raised, collaboratively examine the relationship and your therapeutic style. Are you practicing cognitive therapy in an overly prescriptive manner, referring constantly to worksheets and exercises even when rapport is absent? The therapy relationship is especially central with clients with personality disorders. It is important to maintain good eye contact, express caring and interest in the client, and listen well with empathic comments. Clients react to written work best within a strong collaborative relationship. With many clients with personality disorders, this relationship needs to be reestablished in each session.

Therapists also err if they push therapy too quickly. Session pacing is important. Do not ask six rapid-fire questions. Instead, ask a question, make a reflective response, pause, ask another question, and make frequent summaries of what you hear to allow the client a chance to check the accuracy of your perceptions. Another common therapist error is asking questions in a challenging fashion (e.g., “Are your sure that’s what he meant?”), which contributes to a client perception that the therapist distrusts client perceptions. It is much better to pursue guided discovery in a manner that respects client perceptions and at the same time encourages the client to consider alternatives:

C:   He just about came out and said he thought I was a loser.

T:   What was it about how he said it that gave you that impression?

C:   He had a superior look on his face. And he didn’t even look me in the eye when he said he wasn’t interested.

T:   I can see how that could convey the idea he thought you were a loser. Did he say or do anything that implied anything different?

C:   No.

T:   Tell me a little more about his style. Did he talk to you any differently than he talks to other people?

C (
pausing
)
:
I’m not sure. He does seem to cut off other people pretty quickly.

T:   Why do you think he does that?

C:   I’m not sure. Sometimes I think he’s not very comfortable since he’s younger than the rest of us.

In this excerpt, the therapist is trying to determine if the client can be sure that his friend meant to say he was a loser. However, instead of directly challenging the client’s conclusion, the therapist helps the client identify the data that led to the conclusion and then begins to look for data that might support alternative interpretations. The Thought Records in the treatment manual follow the same pattern: Clients are asked to write down “Evidence that Supports the Hot Thought” before considering “Evidence that Does not Support the Hot Thought.” If therapists are intent on disproving distressing thoughts, the therapy process loses credibility; clients perceive that the therapist is discounting negative aspects of their life experience. Good cognitive therapy helps clients face both positive and negative aspects of their experiences.

Sometimes the structure of the therapy needs to be modified to support a client’s learning style. Clients who become anxious with math may wish to use color rating scales or use pictures or a pie chart instead of a scale. Schemas also may lead to modifications in the structured aspects of therapy. For example, some clients with histrionic personality disorder find the exercises more interesting when they relabel them with more dramatic titles in their own words. For example, a client might rename the Thought Record “Moods, Mind Games, and My Answer!”

One client had the schema “I must perform perfectly or others will leave me.” She worked so diligently to please her therapist that each exercise in the treatment manual took her one hour or more to complete, and even then she was anxious that it would not be good enough. To reduce the schema-driven anxiety related to structured therapy worksheets, the therapist asked her to leave each exercise partially incomplete and to intentionally cross out words on the worksheets to make them appear less perfect. This adjustment, while initially distressing, helped the client reduce her perfectionism and provided early behavioral experiments to support schema change.

Remember that the importance of structure in cognitive therapy is to enhance learning. If structure impedes learning, it should be modified. Therapists who are ambivalent themselves about structure sometimes eliminate structure if clients object to structure. This is usually a therapeutic error. Sometimes clients who have the most difficulty following a structured therapy approach are those who benefit most by learning to be more structured. Therefore, it is best to reduce or modify therapy structure rather than eliminate it. Most clients readily follow a structured therapy approach if the therapist listens to concerns about structure, clearly explains the advantages of the structure employed, and is willing to modify the structure in response to client concerns.

If client and therapist cannot reach agreement on the degree and type of structure that is therapeutically ideal, behavioral experiments can be used to evaluate each person’s ideas. One session or a portion of each session can be conducted following the structural desires of the client (e.g., “No questions, no writing, I just talk”) and another session or portion can follow the therapist’s proposal (e.g., “I ask occasional questions and help you write summaries or diagrams to connect your emotions and thoughts”). Following the experiment, both therapist and client can describe what was helpful and not helpful about each approach. The two then search for a compromise therapy plan that incorporates the useful aspects of both structures (e.g., “I will signal you when I want to talk without questions or summaries. After five minutes of listening, you will summarize what you’ve heard. If we decide there is an important idea, we will write it down”).

It is not unusual for clients with personality disorders to be convinced that they cannot change. Psychotherapists often share this opinion, indeed part of the definition of personality disorders is that they are “enduring patterns” of “inner experience and behavior” that are “inflexible” and “stable.” (APA, 1994, p. 629) It is countertherapeutic for therapists to believe that a client cannot change because therapist expectation influences therapist behavior and therapy outcome. For example, a therapist who believes that a client cannot change may initiate a therapy plan for change but accept stagnation in progress as inevitable. In contrast, a therapist who believes change is possible actively problem solves when progress is stalled and makes adjustments in the therapeutic plan until change is achieved. It is helpful for therapists to ask themselves, “What would I do with a client who did not have a personality disorder diagnosis if I ran into this difficulty?” Or, “If change is inevitable, how can I alter the treatment plan to help it come more quickly?”